OBSERVATIONS 



SOME OF THE PHYSICAL, CHEMICAL, PHYSIOLOGICAL 
AND PATHOLOGICAL PHENOMENA 

OP 

MALAEIAL FEVER. 

BY 

JOSEPH JONES, A.M., M.D., 

PKOFESSOR OP MEDICAL CHEMISTRY IN THE MEDICAL COLLEGE OF GEORGIA, AT AUGUSTA. 



EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 



PHILADELPHIA: 
COLLINS, PRINTER, ^05 JAYNE STREET. 



INTRODUCTION. 



These "Observations on some of the Phenomena of Malarial 
Fever," form the first of a series of observations which the author 
is conducting upon the fevers of the North American Continent. 

The first three chapters are devoted to the consideration of the 
nature and extent of Pathological Investigations, and are intended 
as a general introduction to the whole series of investigations. 

No one is more painfully alive to the imperfections of these 
incomplete observations than the author; and if they should result 
in inducing a single yonng man to enter this field, with correct 
views and the right spirit, he will feel that he has been rewarded 
for his labors. 



CONTENTS. 



liXTRODUCTlOX . . p. 3 

CHAPTER I. 

RELATIONS OF MAN TO THE EXTERIOR UNIVERSE. 

Relations of astronomical, terrestrial, physical, chemical, and physiological phenomena — 
The character and extent of physiological and pathological investigations established by 
the relations of man to the exterior universe ...... pp. 7 — 49 

CHAPTER II. 

The EXTENT, OBJECTS, AND IMPERFECTIONS OF PATHOLOGICAL INVESTIGATIONS. 

pp. 50 — 75 

CHAPTER III: 

THE BLOOD. 

Imperfect state of our knowledge of this fluid — Imperfections in the methods of analysis — 
Importance and difficulty of establishing a standard formula of the composition of the 
blood in health — The composition of the blood varies not only with the class, but with 
each species of animals, and corresponds with the development of the organs and appa- 
ratus ; illustrated by the development of the blood and organs of invertebrate and 
vertebrate animals — Standard of Lehmann, and of Beequerel and Rodier — Importance 
of determining the changes of the blood during thirst and starvation — Importance and 
difficulty of determining the amount of blood in the system . . . pp. 75 — 87 

CHAPTER lY. 

CHANGES OF THE BLOOD IN MALARIAL FEVER. 

Difficulties of the investigation — Color of the blood and serum in malarial fever — Specific 
gravities and coagulation of the blood in malarial fever and other diseases — Fibrin 
decreases in malarial fever — Formation of heart-clots in congestive fever during life — 
Occurrence of heart-clots in other diseases — Conditions most favorable to the deposition 
of fibrinous concretions — Symptoms and diagnosis of fibrinous concretions in the heart 
and bloodvessels — Perilous effects resulting from the detachment of fibrinous concretions 
Imperfect state of knowledge, with reference to the formation of fibrinous concretions in 
the living body — Cause of the coagulation of the blood unknown — Principles of treatment 
best adapted to prevent the formation of fibrinous concretions in malarial fever — Phy- 
sical and chemical changes of the constituents of the blood in malarial fever — Illustra- 
tive cases — Relations of the cerebro-spinal and sympathetic nervous systems to the 
changes of the blood and organs in malarial fever — Grangrenous erosion of cheek follow- 
ing malarial fever — Comparison of the changes of the blood in malarial fever with the 



CONTENTS. 



changes in marsh cachexia — Mechanical dropsy — Acute dropsy — Cachectic dropsies — 
Alterations of the colored blood-corpuscles in malarial fever — Principles of treatment 
suggested by the changes of the blood in malarial fever — Effects of bloodletting — Of 
excessive purgation — Of nutritious diet and stimulants — Of phosphates — Of pepsin — 
Determination of the place of the destruction of the colored blood-corpuscles in malarial 
fever — Constitution of the blood in various diseases, in typhoid, typhus, and ephemeral 
fevers — In smallpox, scarlatina, measles, scurvy, erysipelas, cholera, phthisis, scrofula, 
carcinoma, Bright's disease, chlorosis, anemia, rheumatism, puerperal fever, pneumonia, 
peritonitis, angina tonsillaris, bronchitis, carditis, pericarditis, inflammation of brain, 
glanders, lead-poisoning — The colored blood-corpuscles are more uniformly and rapidly 
destroyed in severe cases of malarial fever than in any other acute disease — Diminution 
of fibrin in malarial fever corresponds to the severity of the disease — Discussion of the 
question. Do these changes of the blood precede, or succeed, or are they simultaneously 
with, the aberration of the physical, chemical, vital, and nervous phenomena, denomi- 
nated fever? pp. 88— 216 



CHAPTER Y. 

CHANGES OF THE ORGANS, AND TISSUES, AND APPARATUS OF THE BODIES OF THOSE 
TVHO HAVE DIED WITH THE DIFFERENT TYPES OF MALARIAL FEVER, INTERMITTENT, 
REMITTENT, AND CONGESTIVE COMPARISON OF THESE CHANGES WITH THE PHENO- 
MENA OF MALARIAL FEVER AND WITH SIMILAR CHANGES IN OTHER DISEASES, AND 
WITH THE ORGANS, TISSUES, AND APPARATUS OF MEN AND ANIMALS IN THE NORMAL 
CONDITION. 

Exterior — Muscular system — Cerebro-spinal nervous system — Dura mater, arachnoid 
membrane, pia mater, cerebrum, cerebellum, medulla oblongata, ventricles of brain 
— Cerebro-spinal fluid — Nervous phenomena of malarial fever compared vs^ith post- 
mortem examinations — Causes of aberrated nervous phenomena in malarial fever — 
Theory expressing the relations of the physical, chemical, and nervous phenomena of 
malarial fever— Malarial fever paroxysmal, not because the action of the cerebro-spinal 
or of the sympathetic nervous system is paroxysmal — Explanation of the paroxysmal 
character of malarial fever — Lungs — Heart — Alimentary canal — Tongue — Stomach — 
Intestinal canal — Liver — Weight of liver in malarial fever — Post-mortem examinations 
illustrating the changes of the color of the liver in malarial fever — Effects of previous 
pathological alterations upon the color — Changes of the color of the blood in the liver of 
malarial fever — Sources of the change of color in the liver during malarial fever — 
Character of the bile in malarial fever — The liver of those cases which died in the active 
stages of malarial fever contained animal starch, whilst hepatic sugar was absent — Points 
of difference between the malarial fever and yellow fever liver — Spleen, pathological 
alterations of, in malarial fever — Pancreas — Kidneys .... pp. 216 — 271 



CHAPTER VI. 

CIRCULATION, RESPIRATION, TEMPERATURE, STATE OF THE SKIN, TONGUE, AND CHANGES 

OF THE URINE IN INTERMITTENT, REMITTENT, AND CONGESTIVF FEVER PRINCIPLES 

OF TREATMENT BASED UPON THESE OBSERVATIONS ILLUSTRATED BY NUMEROUS 

CASES. 

Importance of determining the pulse, respiration, temperature, and changes of the urine 
in health and disease — Variations of the pulse, respiration, and temperature of different 
individuals and races — Intermittent fever — Cold stage — Illustrative cases — Phenomena 
of hot stage and period of intermission — Illustrative cases — Appearance of tongue — 
Characters of urine — Phenomena of remittent and congestive fever, with numerous illus- 
trative cases — Comparative view of the phenomena of intermittent, remittent, and con- 
gestive fevers pp. 271—407 



OBSERVATIONS ON SOME OF THE PHYSICAL, CHE- 
MICAL, PHYSIOLOGICAL, AND PATHOLOGICAL 
PHENOMENA OF MALARIAL FEYER. 



CHAPTEE I. 

RELATIONS OF MAN TO THE EXTERIOR UNIVERSE — RELATIONS OF ASTRONO- 
MICAL, TERRESTRIAL, PHYSICAL, CHEMICAL, AND PHYSIOLOGICAL PHENO- 
MENA — THE CHARACTER AND EXTENT OF PHYSIOLOGICAL AND PATHOLO- 
GICAL INVESTIGATIONS ESTABLISHED BY THE RELATIONS OF MAN TO THE 
EXTERIOR UNIVERSE. 

The object of this chapter is to sketch the mutual relations of 
celestial and terrestrial bodies and animated beings, and demon- 
strate — that the existence of man is absolutely dependent upon the 
relations of the component members of the universe — that a single 
alteration in the chain of phenomena would destroy the conditions 
necessary for the existence and manifestation of the phenomena of 
man — that the forces of man are all resultants of the forces of the 
sun and fixed stars, which keep up a never ending circulation and 
change of matter upon the surface of our globe — that man cannot 
create or annihilate force any more than he can create or annihilate 
matter — that the great law of the Indestructibility of Force, of 
Action, and Eeaction, applies to all the phenomena of man — that 
man is a type of the universe, and comprehends within himself all 
phenomena, astronomical, physical, chemical, physiological, and 
psychological — that the knowledge of the structure, phenomena, 
and relations of man includes a knowledge of all science, whether 
relating to matter or mind. The end of the whole investigation 
will be the establishment of the true character and extent of phy- 
siological and pathological investigations. 

In this inquiry we will examine first the general or simple phe- 
nomena, and lastly the particular or complex. 

There are certain phenomena, as gravity, which affect all bodies, 
and at the same time appear to be wholly independent, in their 



8 



OBSEKVATIOXS OX 



existence and manifestation, of all other phenomena. These phe- 
nomena have been callecV general or simple, because they appear 
to be not only independent in their own existence of all other 
phenomena, but they form the foundation of the manifestation and 
conditions of the existence of all other phenomena. 

We have another class of phenomena which are confined to cer- 
tain forms of matter, and whose existence and manifestation depend 
upon definite circumstances and the pre-existence of the general 
phenomena. These phenomena are called complex or particular. 
Thus the law of gravity, which (so far as our means of observation 
extend) affects every molecule of matter throughout the universe, 
is an instance of a general phenomenon ; whilst physiological phe- 
nomena, Vvdiich are manifested by only a comparatively small num- 
ber of bodies, are instances of complex or particular phenomena. 

General phenomena are wholly independent of the particular 
or complicated ; whilst the particular or complicated are dependent 
upon the general, and cannot exist without them. Thus, we cannot 
conceive of matter without weight, but we do conceive and know 
of the existence of matter in a state of perfect freedom from the 
manifestation of physiological phenomena. It is evident that if we 
wish to understand the complex phenomena, we must analyze the 
component phenomena, and examine first the most general, which 
form the foundations of the existence and manifestation of the 
restricted or complex. 

Man stands upon the summit of a pyramid, the foundation of 
which is the inorganic world, and the materials composing this 
pyramid consist : first, of plants in various stages of development, 
the simple extending downwards, the more complicated extending 
upwards, diminishing in numbers as they increase in complexity ; 
and, secondly, of animals in various stages of development, increas- 
ing in complexity and diminishing in numbers as they extend 
upwards. To understand the physical and physiological constitu- 
tion of man, we must commence at the base of the pyramid and 
examine successively all the elements, with their properties, forces, 
and constitution — we must examine the relations of the individual 
elements to each other and to the universe. 

' That the true principles of the classification of the phenomena of the universe 
were recognized by the ancients, as well as "by the moderns, is demonstrated bj 
the fact that the historical development and classification of the sciences correspond 
with the logical classification. The principles of classification and the relations of 
the sciences have been discussed in a master] v manner by Auguste Comte in his 
Positive Philosophy. 



MALARIAL FEVER. 



9 



Upon the present occasion we can do nothing more than present 
a general outline of this immense subject, for the complete know- 
ledge of the intellectual and moral constitution of man alone 
requires the knowledge of the relations of the moral and intel- 
lectual faculties of man to the material structures by which they 
are surrounded — requires the knowledge of the relations of the 
moral and intellectual faculties to the physical, chemical, vital, 
muscular, and nervous forces — requires the knowledge of the 
nature, origin, and development of all science — requires the know- 
ledge of the constitution, and phenomena, and progress of the 
moral and intellectual faculties as revealed in all history, scientific, 
civil, and religious, past and present. 

If it be admitted that the art of medicine will attain to the rank 
of a science only when its relations with all the branches of know- 
ledge are recognized and demonstrated, it must also be admitted 
that the present attempt to establish a standard for physiological 
and pathological investigations by the presentation of a general 
view of the relations of man to the exterior universe, incomplete 
and imperfect though it be, is an effort in the right direction. 

In the survey of the universe all natural phenomena have been 
divided into two great classes, celestial and terrestrial. 

Astronomical phenomena affect all bodies, whether they belong 
to this world or to the universe, and at the same time they may be 
said to be independent of all others. All bodies attract each other, 
in direct proportion to their masses, and in inverse proportion to 
the squares of their distances — this law, which is the sublimest of 
all generalizations, and the foundation of the science of astronomy, 
affects all bodies, inorganic and organic, inanimate and animate. 
The researches of astronomers are constantly enlarging our con- 
ceptions of the wide reign of the law of gravity. In every one of 
those wonderful binary systems of stars,^ which have been sufB.- 

' The number of double stars (those both optically and physically double) 
observed by Sir William Herschel (1776—1804) ; by Otto Struve in Pulkowa 
(from 1813 to 1842) ; by Sir John Herschel (from 1819 to 1838) ; by Bessel ; by 
Argelander at Abo (1827—1835) ; by Encke and Galle at Berlin (1836 and 1839) ; 
by Preuss and Otto Struve in Pulkowa (since the catalogue of 1837) ; by Madler 
in Depart ; by Mitchell in Cincinnati, U. S. ; and by several other astronomers — 
may be estimated, with some certainty, at 6,000. The number of the double stars, 
the elements of whose orbits it has been possible to determine, is stated at present 
to be 16. History of the Royal Society, vol. iii., 1757, p. 225. An Inquiry into 
the Probable Parallax and Magnitude of the Fixed Stars, from the Quantity of Light 
which they afford us, by the Rev. John Mitchell, Philos. Trans., vol. Ivii. pp. 234 

2 



10 



OBSERVATIONS ON 



ciently examined, the two systems are found to obey unswervingly 
Kepler's two laws, from which, by Newton's process, we infer that 
these grand orbs are held together by the force of gravity. The 
vast ocean of space and matter under the dominion of the force 
of gravity, even supposing it to be limited to these double suns, 
revolving around their common centres of gravity, is beyond all 
comprehension, for the light from many of these systems has to 
travel years and even centuries^ before reaching our globe. A faint 

—261. Outlines of Astronomy, bv Sir Jolin F. W. Herschel, Philadelphia, 1855, 
p. 475. Popular Astronomy, by Francis Arago, London, 1855, pp. 288 — 317. The 
Architecture of the Heavens, by J. P. Nichol, LL. D., London, 1851, pp. 165 — 268. 
Cosmos, a Sketch of a Physical Description of the Universe, by Alexander Von 
Humboldt, trans, by E. C. OttS, London, 1851, vol. i. pp. 136 — 139, vol. iii. pp. 
271—289. 

' Nichol's Architecture of the Heavens, p. 13. 

Distances of the various orders of stars from our solar sphere. 



Apparent magnitudes. 


Distances of the exterior 
limit of the various orders 
expressed in radii of the 
earth's orbit. 


Xumber of years 
occupied by light 
in traversing those 
distances. 


1 


1,246,000 


19.6 


2 


2,111,000 


33.3 


3 


3,151,000 


49.7 


4 


4,375,000 


69.0 


5 


6,121,000 


96.6 


6 


8,746,000 


137.9 


7 


14,230,000 


224.5 


8 


24,490,000 


386.3 


9 


37,200,000 


586.7 



According to astronomers the light of the most distant stars requires not merely 
centuries, but thousands of years to reach our globe. Our conception of the extent 
of the reign of the law of gravity is farther widened when we consider not only 
the immense distances of the stars from our earth, but also the immense orbits 
described by these double stars around their common centre of gravity, and 
especially the immense periods of time required for the completion of a single 
revolution. 

The following table, illustrating the periods of revolution of these double stars, 
has been selected from Madler's extensive list : — 

Period of revolution 



Stars. in years. 

210 Herculis ...... 131 

^ Bootis ...... 435 

49 Cephi ...... 466 

I Hydrae ...... 584 

1 Leonis ...... 561 

42 Ceti ...... 696 

1 Cassiopeise, 1 pair . . . . . 1,065 

" 2 pair . . . . . 2,785 

y Leonis ...... 1,342 



MALARIAL FEVER. 



11 



conception of the immensity of the distance may be formed, when we 
reflect that light passes over 191,515 English miles in one second. 
The grand march of our sun, with his attendant planets, through 
the great ocean of space, at the annual rate of 154,185,000 miles,^ 
around a distant unknown centre, supports still more strongly the 
conclusion, that all the particles of matter in the universe are mu- 
tually related. Without this fixed relation of all the individual 
and component molecules of the universe, matter could not exist 
in its present condition. Destroy the mutual attraction of bodies, 
and the essential conditions for the existence of the universe will 
be destroyed. The existence of this law is independent of all others, 
and of every form, property, and affection of matter ; whilst all the 
properties and affections of the various forms of matter, inorganic 
or organic, depend ultimately upon the existence of this fixed rela- 
tion of the molecules of matter. If our sun with his planets were 
blotted out of existence, this fixed relation of the remaining mole- 
cules of matter would not be destroyed. If sun after sun, and 
system after system, were blotted out of existence, it is reasonable 
to believe that this law would not be destroyed as long as two 
atoms of matter remained. 

The atoms of matter are bound together by a force which acts 
only at insensible distances, called the force of cohesion. It has 
been announced by some philosophers that the force of cohesion is 
nothing more than the force of gravity, acting between the indivi- 
dual atoms of bodies, at exceedingly small distances. Be this as it 

Period of revolution 



Stars. in years. 

y Ceti ... . . . . 1,478 

a Piscium ...... 2,928 

^ Coronje ...... 3,542 

■vf- Cassiopeise ...... 5,468 

Polaris ...... 6,069 

^ Ursse Majoris ...... 7,659 

y Andromedse ...... 10,376 



The periods occupied by the motions of sun around sun are exceedingly various, 
some occupying but a brief and rapid cycle of fifteen or sixteen years, and others 
occupying thousands ; whilst in others the changes are so slow that they are 
almost imperceptible, and betoken circuits of immense spaciousness and duration. 

' J. F. W. Herschel's Outlines of Astronomy, p. 494. Arago's Popular Astro- 
nomy, p. 363. Bessel in Schum, Jahrb. ftlr 1839, s. 51. Arago in the Annuaire, 
1842, pp. 388—399. Argelander, On the Proper Motion of the Solar System, 1837, 
s. 43. Otto Struve in the Bull, de I'Acad. de St. Petersb., 1842, t. x., No. 9, pp. 
137 — 139. Nichol's Architecture of the Heavens, p. 242. Humboldt's Cosmos, 
vol. i. p. 134. 



12 



OBSERVATIONS ON 



may, it is evident that if matter be deprived of these two forces 
of cohesion and gravitation, its properties of form, color, porosity, 
compressibility, dilatability, and elasticity, would cease to exist, 
and the manifestation of its peculiar affections or motions, as heat, 
light, electricity, and magnetism, would be impossible. Without 
these properties of matter no organized plant or animal could exist 
in any portion of the universe, constructed upon the same plan with 
those of our globe. 

When we turn our eyes from a general survey of the universe 
to our own system, we discover that its present state depends abso- 
lutely upon the mutual relations of its component parts. 

Mathematicians, reasoning upon the necessary results of the law 
of gravity in producing mutual disturbances in the motions of the 
planetary bodies, came to the conclusion that our system contained 
within itself the elements of its destruction. They thought that 
they could demonstrate that derangement must ensue from the 
mutual action of the heavenly bodies upon each other — they thought 
that they could calculate its progress with the utmost exactness, 
and predict the time when the whole system would be destroyed 
by the action of the law of gravity, which, when first discovered, 
appeared to be the great principle of motion and stability. The 
fallacies of these calculations and falsity of these prophecies have 
been exposed by the sublime discoveries of Lagrange and Laplace, 
which have shown that the relative distances, sizes, orbits, and 
periods of revolution of the planets are so nicely adjusted that the 
mutual perturbations counterbalance each other, so that, amidst 
numberless conflicting, disturbing, destructive influences, unity, 
harmony, and stability result. 

The order and harmony of our system give unmistakable evidence 
of the working of one great omnipotent mind. The plan of each 
planet is the type of the whole system. Thus, all the planets 
revolve around the sun in the same direction, from west to east, 
which is the direction of the rotation of the sun on his axis ; all 
the planets rotate on their axes also in the same direction, all the 
satellites move around the primaries in the same direction, and 
almost all the planets and satellites move around the sun in nearly 
the planes of the sun's equator. From these arrangements it results 
that they all have the succession of day and night, and vicissitudes 
of the seasons. As far as the observations of astronomers have 
extended, it appears that the planets are constructed and arranged 
upon the same plan with our earth. The surface of one is diversi- 



MALARIAL FEVER. 



13 



fied with mountains, valleys, and plains — another is surrounded by 
an atmosphere apparently having analogous motions (trade-winds) 
to those of our own atmosphere — the surface of the red colored 
Mars is divided into green seas and red continents, and as his 
winter advances a white color spreads over his northern regions, 
and as summer approaches this whiteness disappears, thus showing' 
that a fluid exists upon his surface, which, like water, is congealed 
by cold, and dissipated by heat — and many of them have their 
satellites, which, like our own moon, rule the. night. It is not 
reasonable to suppose that the blazing sun should shine by day, 
and the gentle satellites by night, upon mere dead masses of matter 
moving forever silently and fruitlessly through space. These beau- 
tiful arrangements force upon us the belief that the members of 
our solar system are inhabited by beings, which, probabl}^, from 
the very arrangements themselves, are analogous to those inhabiting 
our globe.^ If they be inhabited by similar beings, the existence 
of these inhabitants must depend absolutely upon the mutual rela- 
tions of the component members of the system. 

The (ruth of this assertion is evident when we consider the 
relations of the organized beings inhabiting our globe to the size, 
density, and structure of the earth, and to its relations with the 
sun and all other members of our system. 

The plants and animals of our globe have all been constructed 
with exact reference to its structure, its mass, its power of gravity, 
and the forces of the sun and sister planets. If the mass, and 
density, and force of gravity of our earth were increased, the density 
of the atmosphere would be correspondingly increased, and the 
respiration and circulation of animals and plants would be greatly 
interfered with, if not completely arrested — the rise of the sap in 
plants, which is due to the physical force of endosmose, which in 
this case acts antagonistically to gravity, would be counterbalanced 
and completely checked, and the elaboration of the sap, and the 
nutrition and growth of plants, absolutely prevented — the muscular 
strength of animals would be inadequate to the continued support 
and active movement of their bodies; the swiftest animals would 
crawl like sloths ; and the once active and energetic lords of crea- 
tion, instead of directing and controlling the powers of nature, 

' "Discourses on tlie Cliristian Revelation viewed in connection witli tlie Modern 
Astronomj," by Thomas Chalmers. "The Plurality of Worlds." "More Worlds 
than One," by Sir David Brewster. " The Unity of Worlds and of Nature," by the 
Rev. Baden Powell. 



14: 



OBSEEVATIONS ON 



would drag out miserable existences, moving as if under heavy 
burdens, exhausted by the slightest mechanical effort. On the other 
hand, if the mass and force of gravity of our planet were greatly 
diminished, the atmosphere would be correspondingly rarified — 
the respiration, and circulation, and nutrition of animals and plants 
disturbed — the development of their physical and chemical forces 
retarded and disturbed, and their situation and motions rendered 
unstable.^ 

The relations of the moon with our earth are of the most im- 
portant character. Her influence is not confined to ruling the 
night, lighting the mariner and traveller, and exciting joy in the 
hearts of all by her soft and silvery beams. The weight of the 
moon and her distance from the earth have been appointed by the 
great Architect with exact reference to the size and density of our 
globe, its distance from the sun, its relations with other planets, 
and the constitution of its atmosphere and crust, and the structure, 
forces, and wants of plants and animals.^ 

The distance of the earth from the sun has been arranged with, 
exact reference to the structure of the surface, and the constitution 
and preservation of its organized beings. Were the distance of 
the earth from the sun increased or diminished, or the inclination 
of the plane of its orbit increased, or the nearly circular orbit 
rendered as eccentric as the orbit of a comet, the alternations of 
seasons, the climate, and constitution of many bodies^ upon the 

' " Astronomy and Greneral Physics considered witli reference to Natural Theo- 
logy," by Rev. William Whewell, D. D. 

2 If the moon had been placed much nearer the earth, or had been much larger 
than it is, the tides of the oceans would have run so high that large tracts of 
land would have been uninhabitable, and navigation rendered dangerous, if not 
impossible. 

We may form some idea of the influence of the moon upon this earth, by con- 
sidering the fact, that, owing to its proximity to the earth, the agency of the moon 
in producing tides in the waters of the oceans, and in the atmosphere, is from 2^ 
to 2^ times greater than that of the sun. 

The rise of the tide not only aids greatly navigation, by its repeated flow into 
numerous harbors, rivers, and creeks, which would, on account of their shallow- 
ness, be useless for the purpose of navigation, but it also difi'uses the saline 
ingredients of the oceans, washed from the strata at their sides and bottom, and 
from the continents through which the rivers flow, and thus maintains the purity 
and uniformity of the waters. Without this perpetual agitation, it is probable 
that the waters of the oceans would become unfit for animal and vegetable life. 

The attraction of the sun and moon produces corresponding tides in the great 
ocean of gaseous matter surrounding our globe. These motions in the atmosphere 
must, without doubt, exert decided influences upon organized beings. 



MALAEIAL FEVER. 



15 



surface of our globe, would be greatly altered, and the chemistry 
of organized beings deranged* The sun is a great centre of che- 
mical as well as of physical influences, and should he be blotted 
out of existence, or if the intensity of these chemical and physical 
influences be lessened or increased, either by an actual diminution 
or by a change of the distance from the sun to the earth, not a 
vegetable or animal could exist upon this globe, because the sun's 
heat and chemical influences are absolutely indispensable to the 
growth and existence of plants. If vegetation be destroyed, as a 
necessary consequence all animal life, with its chemical composi- 
tions and decompositions, must cease, because animals, whether 
herbivorous, or carnivorous, or omnivorous, derive the materials 
for the nutrition of their structures, and the development of the 
forces which work their machinery, ultimately from vegetables. 

The sun, and all the countless fixed stars of the material universe, 
are the sources of the heat which preserves matter in its present 
conditions upon the face of our globe, and supplies the essential 
conditions for the existence of organized beings.' 

* The states of matter, solid, fluid, and gaseous, are relative and not absolute. 
The existence of matter in one or the other of these states depends upon the forces 
acting upon the atoms. The atoms of matter are not in immediate contact with 
each other. The distance of the atoms from each other, and the stability of the 
matter which they form, depend upon the action of two antagonistic forces, cohesion 
and heat. Heat corresponds to the repulsive centrifugal force, and cohesion to 
gravitation, the attractive centripetal force. According to this view a particle of 
matter is a type of our solar system ; it is composed of smaller bodies, held in 
definite positions and accomplishing definite movements by two apparently antago- 
nistic forces. In the solid state the attractive cohesive force is stronger than the 
repulsive force of heat. In the fluid state, whilst the attractive force preponderates 
over the repulsive, the two are more nearly balanced, and the polarity of the particles 
is overcome, and they are movable in all directions, and transmit forces equally 
in all directions. In the gaseous state the repulsive force, heat, is stronger than 
the attractive cohesive force, and the particles have lost their polarity. The exist- 
ence, then, of matter in one or the other of these states depends upon the tempera- 
ture. As far as our means of observation extend it may be asserted that all the 
various forms of matter may be made to assume these states successively by a 
variation of the temperature. Thus, the metals are solids at ordinary tempera- 
tures. When heat is applied they become fluid, and if the heat be continued they 
become gaseous. Many of the gases have been reduced first to fluids, and secondly 
to solids, under a reduction of temperature and increased pressure. 

One of the essential conditions of all animals and vegetables is that they possess 
a large amount of fluid. Without this fluid the important acts of circulation, 
nutrition, secretion, and excretion, and the preservation of a definite form during 
unceasing chemical compositions and decompositions, could not be maintained. 
If animals and vegetables be deprived of fluid, all motions amongst the individual 
molecules must cease. 



16 



OBSERVATIONS ON 



The fixed stars, although analogous to our sun, are at so great 
distances that it seems unreasonable to attribute to them any influ- 
ence over the changes going on upon the surface of our globe. 
When, however, we consider that scarcely a line can be projected 
into space from any point upon our globe without eventually 
striking one of these suns — when we consider that in some places 
many thousands appear to be gathered into a space no greater than 
that occupied by the disk of the full moon, it will be no longer a 
matter of surprise that they should exert a decided influence upon 
the temperature of our globe. 

M. Pouillet,^ from an elaborate series of experiments upon solar 
and stellar heat, finished in 1838, drew the following remarkable 
conclusions : — 

1. That the actual temperature of space in which the earth and 
planets move lies between — 175° and — 283° Fahr. 

2. That the sun supplies the earth annually with as much heat as 
would melt a layer of ice 100 feet thick, covering the entire globe. 

3. That the fixed stars supply as much heat as would melt a layer 
of ice 85 feet thick, covering the whole globe. 

According to this calculation, the solar heat alone constitutes 
only two-thirds of the entire quantity of heat supplied to the earth, 
to repair its losses by radiation into space. If this calculation be 
true,^ it is evident that if the heat supplied by the fixed stars be 

' Memoir on the Solar Heat, on the Radiating and Absorbing Powers of the 
Atmospheric Air, and on the Temperature of Space, hy M. Pouillet, Member of the 
Royal Academy of Sciences of Paris, Professor of Natural Philosophy in the Faculty 
of Sciences, &c. Comptes Rendus des Seances de TAcademie des Sciences, July 9, 
1838. See Translation in Taylor's Scientific Memoirs, 1846, vol. iv., article iii. 
pp. 44—90. 

2 Whether these conclusions of Pouillet be true or false, they are sustained by 
the researches of the best observers, in that they agree in assigning to the regions 
of space a definite temperature. Thus, Fourier,-^ from a careful series of investi- 
gations, estimates the temperature of space at from — 580 to — 760 ; Arago,f from 
polar observations, at — 70O, and Pictet at — 760 ; Saigey, from 367 observations 
made by Humboldt in the chain of the Andes and in Mexico, at — 850, and from 
thermometrical measurements at Mount Blanc and during the aeronautic ascent of 
Gay-Lussac, at — 107 ; Sir John HerschelJ at — 132, and Poisson§ at only 80.6. 

* Th^orie Analytiqiie de la Chaleur, 1S22, p. ix. (AnnaTes de Chimie at de Physique, torn, iii., 
1S16, p. 350; torn, iv., 1817, p. 128 ; torn, vi., 1817, p. 259 ; torn, xiii., 1820, p. 418.) 

f Arago, Sur la temperature du p61e et des e.spaces celestes, Annuaire du Bureau des Long, pour 
1825, p. 189, et pour 1834, p. 192 ; also Saigey, Physique du Globe, 1832, pp. 60—76. 

+ Edinburgh Eeview, vol. 87, 1848, p. 223. 

§ Poisson, Th^orie Mathematique de la Chaleur (§ 196, p. 436, § 200, p. 447, and § 228, p. 521, § 227, 
p. 520). See Analysis of the Mathematical Theory of Heat, by S. D. Poisson, in Taylor's Scientific 
Memoirs, vol. i., article vi., 1837, p. 122. 



MALARIAL FEVER. 



17 



withdrawn, the physical structure of the surface of our globe would 
be changed, the greatest portion of the ocean would become a crys- 
talline mass, and all animals and plants would be destroyed. 

These results of Pouillet, considered in connection with the 
grand march of our sun, with his attendant planets, through space, 
throw much light upon those wonderful geological revolutions 
which show that regions now covered with ice and snow were once 
covered with the rank vegetation of the tropics. It has been sup- 
posed with reason that our system, in its majestic travels through 
the great ocean of space, has swept into the blazing heat and light 
of some of those splendid suns. At such a period there would 
have been a grand illumination and distribution of heat from pole 
to pole, and the icebergs, and glaciers, and snow of polar regions 
would be succeeded by the luxuriant vegetation of the tropics. 

It is evident that if the rays of the sun and stars possessed no 
heat, or if the distance from the earth to the sun was greatly 
increased, or the stellar radiation greatly diminished, all the various 
forms of matter would be reduced to one form, the solid, and as 
a necessary consequence all vegetable and animal life would be 
destroyed. The solid state is as essential to the existence of organ- 
ized beings as the fluid state. If the distance from the earth to 
the sun was greatly diminished, the heat would be correspondingly 
increased, and all solid bodies would be reduced to fluids, and, if 
the heat be sufficiently intense, to gases — the whole structure of 
organized beings would be deranged, because the solid materials, 
which give individuality to the structures, the organs, tissues, and 
apparatus of plants and animals, would be transformed into unstable 
fluids. 

All the motions in the atmosphere, and in the water, and upon 
the land, are resultants of the combined actions of the sun and fixed 
stars, and the forces of matter composing the globe. An alteration 
of the intensity or direction of one or the other class of forces, will 
necessarily be attended by a corresponding alteration of the struc- 
tures and motions of inorganic and organic bodies.-* 

• The truth, of these propositions can be readily established by the consideration 
of the most important properties and motions of the gases, fluids, and solids of our 
globe, and their relations to animated beings. 

The atmosphere, like all gases, is capable of indefinite expansion under a 
diminution of pressure or increase of heat, and of indefinite contraction under an 
increase of pressure or diminution of heat. It is perfectly elastic, and the particles 



18 



OBSERVATIOXS ON 



(Jpon the property of bodies to expand when under the influence 
of heat, and to contract when deprived of heat ; and upon the pro- 
perty of light gases and fluids to ascend through the more dense; 
upon the rapidity and direction of the earth's revolution on its axis ; 
and upon the structure of the earth's surface (the relations of land 
and water with reference to the absorption and radiation of heat), 
depend the motions in the atmosphere called the trade-winds and land 
and sea-breezes, and the corresponding currents in the ocean. If the 
atmosphere and ocean had been so constituted that currents were 
not excited by heat, they would have been stagnant, motionless — 
the cool sea-breezes, loaded with moisture, which in the heat of 
summer revive the drooping vegetation, and at all seasons of the 
year waft the mariner's ship along, would never have existed — 
the trade-winds, the great movers of commerce, would have been 
unknown — mankind would have been confined to the continent on 
which they were created, because the ocean would have been stag- 
nant, without current, and navigation would have been impossible 
— the surface of our globe would have been a barren desert, sup- 
porting trees only along the borders of the ocean. 

The existence of animated beings is absolutely dependent upon 
the constitution and mutual relations of the atmosphere and watery 
vapor, and the supply of a definite amount of heat. The evapora- 
tion of water continuously from the whole surface of the oceans, 
lakes, rivers, continents, and islands, and the distribution of the 
watery vapor through the atmosphere, require an immense expendi- 
ture of mechanical force.^ 

are self-repellent as long as they are acted upon hj the meclianical force, heat. 
The repellent force of the atoms of the atmosphere and of all gases is nothing 
more nor less than the heat of the sun. Just in proportion as this is removed the 
particles obey the attractive force and approach each other, and it is probable that 
if all the heat was removed the atmosphere and all gases would become as solid 
as the framework of the continents and mountains. 

^ The spaces between the atoms of the atmosphere are devoid of matter, and are 
freely penetrable by the atoms of other gases. When gases come in contact, a 
process of rapid diffusion through the pores of each other takes place, and a uni- 
form mixture is established. Water, when changed from the fluid to the gaseous 
state, possesses all the properties of a gas, and rapidly diffuses itself through the 
vacant spaces between the atoms of the atmosphere. The amount of the watery 
vapor varies with the intensity of the repellent force, heat. As long as the repel- 
lent force, heat, acts with sufficient intensity to overcome the attractive force of 
the earth, the watery vapor will manifest all the properties of the atmosphere. 
The force which excites a motion in the atmosphere will excite a corresponding 
motion in the watery vapor. As the existence of the watery vapor depends upon 



MALAKIAL FEVER. 



19 



The sun and the fixed stars are the sources of the heat or 
mechanical force which keeps up a never-ending circulation of 
water throughout the atmosphere and over the surface of our globe. 
Some idea of the agency of heat in the phenomena of our globe 
may be formed by taking the water which falls upon its surface as 
an evidence of its mechanical power. If we take 60 inches as the 
average annual amount of water which falls in the form of rain, 
dew, hail, and snow, upon the surface of the earth, and 900 feet as 
the average height from which it falls, then the work of the falling 
water would equal 452 horse-powers upon each square mile of the 
earth's surface, and the work accomplished upon the whole surface 
of the earth would equal the enormous sum of 90,880,000,000 
horse-powers. If the united powers of all the steam engines of all 
the nations of the earth be estimated at seven millions of horse- 
powers, then the work accomplished by the solar and stellar heat, in 
merely evaporating and elevating the water from the surface of our 
globe, would be 12,982 times greater than that which could be accom- 
plished by all the steam-engines of the world, supposing them to 
work continually day and night. The immense volumes of water 
flowing in the rivers of the earth existed first in the ocean, then in 
the atmosphere in the form of vapor. The mechanical power of the 
water flowing in these rivers may be taken as an index of the force 
which raised the water from the surface of the ocean, and trans- 
ported it across immense continents. It has been calculated that 
the waters of the river Niagara, during their passage over the 
cataracts and falls, exert a mechanical power equal to 12J million 
horse-powers. The mechanical power of the Niagara Eiver alone, 
is greater than that of all the steam-engines of the world. The 

the supply of a definite amount of heat, it is evident that its existence is condi- 
tional, limited, whilst that of the atmosphere is stable, unconditioned, during all 
the changes of temperature with which man is conversant. Whenever the repel- 
lent force is so diminished that it is unable to overcome the attractive force be- 
tween the atoms, the vapor is transformed into water, and is deposited in the form 
of rain, dew, mist, snow, and hail. 

The conversion of water into vapor is accomplished by the expenditure of an 
immense amount of heat, which may be stated in round numbers to be one thou- 
sand degrees. This heat has no efiect upon the thermometer, because it has been 
transformed into mechanical force, and is occupied in keeping asunder the atoms 
of water. By the law of inertia that force is indestructible, and by the law that 
action and reaction are always equal, this heat will be given out again when the 
particles approach each other. This being the case, we may say with truth that 
water requires for its evaporation an immense expenditure of mechanical force. 



20 



OBSEKVATIONS ON" 



Niagara, ia comparison with the Mississippi, Amazon, La Plata, 
Yenisei, Yang-Tse, Nile, Hoan-Ho, and many others, is only a 
modest, medium sized river. After we have calculated the immense 
mechanical power of the mighty volumes of water flowing in the 
fountains, brooks, torrents, streams, and rivers of the earth, we have 
formed but an imperfect idea of the effects upon our globe of the 
two great forces, gravitation and heat, which influence all heavenly 
bodies, and work throughout the entire universe, for, according to 
the calculation of Pouillet, forty per cent, of heat is absorbed during 
its passage through the atmosphere, and immense quantities are 
expended in expanding and maintaining currents in the ocean and 
atmosphere. 

The water elevated by heat, during its descent upon the earth, 
and passage back to the oceans from whence it came, dissolves and 
wears down the solid mountains and continents. The solid rocks 
are disintegrated, the mineral matters are dissolved, stones and 
masses of rock are loosened from hill-sides, even the very mountain 
peaks are undermined by the trickling water, and every fountain, 
every brook, every mountain torrent, and every river transport 
these materials, and gradually fill up the lakes, and seas, and 
oceans, and build up immense deltas and islands. This everlasting 
round of the waters, carried on by heat and gravitation, prepares 
the surface of the barren rocks for the habitation of plants and 
animals, and tends to level every mountain and fill up every de- 
pression upon our globe. 

The structure of the crust of our globe gives unmistakable 
evidence that in its early history it was a molten mass. When the 
surface cooled it was composed of nothing but rocks and water, a 
dead barren mass, studded with volcanoes and lofty rocks. Geology 
teaches that at this time no plant or animal existed upon our globe. 
It was necessary that the solid barren rocks should be disintegrated, 
worn away, the inequalities of the surface filled up, and the crust 
of the earth covered by a loose, pulverized soil, suitable for the 
habitation of plants and animals. This was accomplished by the 
circulation of the water and air, under the action of heat and gravi- 
tation, which at the present day preserves the purity of the ocean 
and atmosphere, waters the thirsty earth, supplies the most im- 
portant elements of the structures of plants and animals, and clothes 
the surface of the earth with a luxuriant vegetation, which elabo- 
rates the materials for the formation and maintenance of all animals, 
from the simple animalcule to the complicated organism of man. 



MALAEIAL FEVER. 



21 



The immense mountain ranges and table lands, whicli influence, 
to a great extent, the climate of continents, and exert an effect upon 
the structure, and growth, and distribution of plants and animals, 
and determine, in a great measure, the habits, occupations, and dis- 
eases of man, have all been elevated by those forces, which rocked 
our earth in its cradle, raised up the mountains, brought low the 
valleys, heaved up immense continents, and divided the sea from 
the main land.* 

To the superficial observer, the angry strife between the great 
forces of heat and gravitation — the blazing volcanoes, belching forth 
burning lava, and deluging the fertile valleys and plains with a 
fier}^ flood — the earthquakes, rocking the globe, fracturing and 
rolling up its strata, heaving up immense continents from the 
ocean's bed, removing the pillars of broad tracts of land and plung- 
ing them far into the bosom of the earth, would appear to be under 
the guidance only of blind, mad fate, chained and struggling in the 
fiery bowels of the earth. It is, however, true that even this fiery 

' The irresistible energy of tlie force of heat is displayed by the discharges of 
gas, steam, mud, and melted lava from the craters of volcanoes, and by the earth- 
quakes which have caused our globe to tremble from pole to pole. On the 19th of 
November, 1822, an earthquake was felt along the eastern coast of South America, 
for the space of 1200 miles from north to south. The whole country, from the foot 
of the Andes to a great distance under the sea, was elevated from two to seven 
feet. One hundred thousand square miles of land, an extent of country almost 
equal to the States of Georgia and Alabama, was elevated, at the lowest calculation, 
three feet. According to the estimate of Sir Charles Lyell, the thickness of the 
rock between the surface of Chili and the subterranean foci of volcanic action may 
have been many miles in depth. If the thickness be estimated at two miles, then 
the mass elevated three feet was 200,000 cubic miles, and equalled in weight 363 
million pyramids. 

The discharge of mud in one year by the river Ganges equals the weight of sixty 
pyramids. It would require IV^- centuries before this river could bear down from 
the continent into the sea a mass equal to that gained by the South American 
continent during a single earthquake. 

In the great eruption of Skaptara Jokul, in Iceland, the volcano threw out a tor- 
rent of lava, which flowed down the sides of the mountain into the Skaptara River, 
completely dried it up, and not only filled the channel of the river, which was 
between high rocks, and in many places from 400 to 600 feet in depth, but over- 
flowed to a great extent the surrounding country, expanded over wide alluvial 
plains, and formed broad, burning lakes, fifteen miles in breadth, and one hundred 
feet in depth. The streams of lava were ninety miles in length, and from seven to 
fifteen in breadth, and from 100 to 600 feet in depth. If we add to this the pumice, 
sand, and ashes scattered not only over the whole island, but to a distance of 300 
miles around, in such abundance as to destroy the fisheries in the neighboring sea, 
the whole amount of matter ejected by the volcano would be millions of cubic yards. 



22 



OBSEEVATIONS ON 



strife is under the guidance of an intelligence who brings unity 
out of diversity and discord, harmony and order out of contending 
forces and elements, life and fertility out of fire and destruction. 
Every earthquake which in past or present times has fractured and 
dislocated the solid strata of the earth, elevated the bed of the 
ocean, or depressed the level of the continents — every volcano 
which has poured forth the liquid contents of the interior of the 
earth — every flood which has swept over the ancient continents, 
has contributed more or less to the formation of a suitable soil for 
the maintenance of plants and animals, and the development of the 
human race. 

The forms, arrangements, and distributions of the terrestrial 
masses, although the results of the action of the forces of heat and 
gravitation, reveal a great design. 

Every form of matter is definitely related to every other form 
of matter upon the face of the globe ; and the combination of these 
various relations, and actions, and reactions of terrestrial masses 
form the essential condition for the manifestation of the great 
designs of the Creator. 

It is a universal law that all the component parts of the universe 
do not have in themselves the entire aim or reason of their 
existence. 

The history of nations has been, in a great measure, determined 
by the agency of heat and gravity upon matter. As man is com- 
posed of inorganic elements, and governed by all the laws, physical, 
chemical, and astronomical, which govern the exterior world, it 
follows as a necessary consequence that the peculiar constitution 
and relations of the inorganic elements of the crust of our globe 
must affect the physical and mental endowments of man. The 
solid portion of our globe is constructed for man just as the body 
is made for the soul. The physical and mental development of the 
different races of mankind has depended, in great measure, upon 
the mutual relations of the solid and fluid portions of our globe. 
This has been demonstrated by a comparison of the physical cha- 
racters of the great continents of our globe with the physical, social, 
and intellectual development of iheir inhabitants.^ 

' "The continent of Africa is without anj great rivers, peninsulas, and bays. It 
is concentrated upon itself, and nowhere lets into its bosom the waters of the sea. 

" Africa has a sea-coast of only 14,000 geographical miles, whilst it covers an 
area of 8,720,000 square miles. 

" Africa has only one mile of coast for 623 miles of surface. It is like a body 



MALARIAL FEVER. 



23 



The chemist, by decomposing, analyzing, and comparing together 
the different forms of inorganic and organic matter, has demon- 
strated that the innumerable forms of matter, rocks, and minerals, 
plants and animals of all colors and shapes, result from the com- 
binations of sixty-two simple bodies, which cannot be resolved into 
any other elements. These elementary bodies unite with each other 
in definite quantities by volume and weight, and each body has its 
own combining weight, which, together with the manifestation of 
the physical forces during chemical combination, appear to depend 
upon the size and arrangement of the ultimate atoms. 

During the union of these elementary bodies the physical forces, 
heat, light, and electricity, are manifested in amount exactly cor- 
responding to the number and arrangement of the elementary 
bodies combining. Whilst each separate substance has its own 
color, form, density, gravity, cohesion, elasticity, and its relations 

■without arms. Its relations with other continents are few and imperfect. It closes 
itself against every influence from without. 

" Without large rivers, without harbors and bays, without peninsulas, it offers but 
few facilities for commerce, the great medium of the interchange of the thoughts 
of nations. 

" The intellect of the African, like the physical constitution of the continent on 
which he lives, is shut up to itself; it is circumscribed by definite boundaries ; it 
is incapable of active relations with surrounding intellects. 

" Of all the continents, Europe is the one whose forms of contour are most varied. 
Its principal mass is deeply cut in all parts by the ocean and by inland seas, and 
seems almost on the point of resolving itself into peninsulas. These peninsulas 
themselves, as Greece, Scandinavia, repeat to infinity the phenomena of articulation 
and indentation of coasts which are characteristic of the entire continent. The 
inland seas, and the portions of the ocean its outer limits inclose, form nearly half 
its surface. The line of its shores is thus carried to the extent of 17,200 miles, an 
enormous proportion compared with its small size ; for it is 3,200 miles more than 
the sea-coast of Africa, which is, nevertheless, three times greater. 

"Europe enjoys one mile of coast for every 156 square miles of surface. Thus, 
it is the continent most open to the sea for foreign connections, and at the same 
time it is the richest in local and independent districts. 

" In Europe we find the greatest number of independent organized kingdoms, the 
greatest variety of interests, and the most continued and rapid intercourse. For 
2,000 years Asia has lost the sceptre of power and civilization, and Europe stands 
unquestionably the first of the civilizing continents. Nowhere on the surface of 
our planet has the mind of man risen to a sublimer height ; nowhere has man 
known so well how to subdue nature and make her the instrument of his intel- 
ligence. 

" The nations of Europe, including the Anglo-American branch, represent not 
only the highest intellectual growth which the human race has attained at any 
epoch, but they rule already every part of the globe, and are preparing to push 
their conquests farther still."— "TAe Earth and Man,'^ by Arnold Guyot, p. 30. 



24 



OBSERVATIONS ON 



to heat, electricity, magnetism, ligbt, and chemical affinity, still 
these properties, and the manifestation of these physical and che- 
mical phenomena, are similar in all bodies, differing in degree and 
not in kind. 

In view of the recent discoveries of science, with reference to the 
equivalents of the physical forces, we believe that we are justified 
in asserting that an equivalent of force is always given out during 
the combination of the elementary bodies corresponding to that 
required to separate those bodies from their compounds (overcome 
the force which united the dissimilar elements), whether that force 
be exerted in the laboratory of the chemist by heat or by electricity, 
or by bringing other chemical affinities into play; or in the labora- 
tories of plants and animals, or in the great laboratory of nature, 
by the action of the heat and chemical forces of the sun. 

In the exertion of every force in the universe, whether between 
the great worlds and systems of worlds, or between the atoms of 
matter, inorganic and organized, whatever be the origin, character, 
or intensity of that force, the great mechanical law holds good. 
Action and reaction are equal. The physical and chemical motions, 
or affections, or forces of matter, mechanical motion, heat, chemical 
affinity, and electricity, are correlative ; that is, they can mutually 
excite, or be converted into each other.^ Whatever hypothesis we 

' In the cells of the galvanic battery we have a chemical action developing a 
physical force or motion (electricity), which may be propagated from particle to 
particle of an insulated wire, of any length ; and if the wires propagating the elec- 
trical excitement be dipped in water or any compound fluid, a chemical action will 
be developed, the extent of which will correspond with the chemical action going 
on in the cells of the battery. 

If the bodies separated from each other by the electrical excitement be united, 
an equivalent of force will be given out corresponding to the force required to 
produce their separation. The force generated during their union may be applied 
to the expansion of tlie water in the boiler of a steam-engine, and thus accomplish 
mechanical effects. Here we have chemical action developing electricity, and this 
in turn developing chemical action, and the union of the products of that chemical 
action giving out an amount of force equivalent to that developed during the 
chemical changes in the cells of the battery. 

If the wires conducting the electrical excitement, instead of being immersed in 
a fluid, be united by a metal which is a bad conductor (or, in other words, retards 
the passage of the electrical excitement), heat will be developed in amount cor- 
responding to the retardation of the electrical excitement. 

The development of heat by friction is considered by philosophers as the con- 
version of motion of masses into motion of the component atoms. In the electrical 
machine we have the development or excitation of electricity by ordinary impeded 



MALAEIAL FEVEE. 



25 



adopt, whether of actual conversion, or of excitement of the different 
forces — the law of action and reaction holds good as far as the 
researches of philosophers have extended, because if there be not 
an actual conversion of one force into another, it is always true 
that the force exciting is diminished in an amount corresponding to 
the excitement of the second force. The direction of a force may 
be changed, it may be subdivided and directed in so many direc- 
tions, and assume so many different modes of force or motion, as to 
escape our observation, or it may be held in abeyance by opposing 
force, just as the action of the steel spring is counterbalanced by 
the force of gravity of a weight ; but it can no more be destroyed 
than matter. 

The three great fundamental laws of motion established b}^ 
Kepler, Galileo, and Newton : — 

1. A body at rest cannot of itself begin to move ; and a body in 
motion cannot change its velocity nor its direction of motion with- 
out the action of some extraneous cause ; any body impelled by a 
single force will move in a right line and with uniform velocity. 

2. Independence or coexistence of motions leading to the com- 
position of forces. 

3. Constant equality of action and reaction ; one body moving 
another body loses precisely as much motion, in proportion to its 
mass, as the body moved gains ; although applied by them to me- 
chanical motions alone, are applicable to all the motions and forces, 
astronomical or terrestrial, of the masses or atoms of inanimate and 
animate bodies. 

The establishment of the truth of these laws for all motions and 
forces, however excited, is necessarily followed by the admission 
that, as far as the powers of finite beings extend, force is indestructi- 
ble. The store of force with which the Creator has endowed mat- 
ter can neither be added to nor detracted from by man, any more 
than he can add to or detract from the store of matter. Without 
this mutual relation of all the different forces, without the conserva- 
tion of force, the universe would not be maintained in its present 
condition. 

motion. Electricity may be generated also by the revolution of the keeper of a 
magnet around the poles of the magnet. 

The action of the steam-engine, and of the locomotive apparatus of every animal, 
demonstrates the correlation of chemical affinity, heat, and mechanical force. 

3 



26 



OBSEEVATIONS OK 



The application of these laws to physical and chemical pheno- 
mena, and the establishment of this wide generalization, has not 
been the work of one mind alone, but of many minds, in different 
countries, often working entirely independent of each other. The 
human mind, from the earliest periods, endeavored to explain the 
origin and order of the universe, and discover some general prin- 
ciple or origin of all things. The early students of nature, the 
founders of the ancient schools of philosophy, endeavored to divine, 
at a single glance, the whole import of the book of nature, and dis- 
cover the origin and principle of the universe. The ancient Hin- 
doos, Sabians, Chinese, Persians, and Egyptians worshipped deities 
which were resolvable into the powers of nature, and were mytho- 
logical personalities of the sun or solar fire. Thales, Parmenides, 
Archelaus, Democritus, Pythagoras, Hippocrates, and many other 
ancient philosophers, maintained the existence of an omnipresent 
fiery aether, as the efficient and primary cause of motion throughout 
the universe, by the energy of which matter was reduced to order 
from chaos, and life infused and maintained in plants and animals. 
Notwithstanding the dimness and vagueness of these cosmogonies, 
which were better suited to the dim magnificence of poetry than to 
exact science, the human mind at the present day adopts a view 
of the physical universe which, if more exact, is certainly not more 
grand. 

Whilst the ancient philosophers failed to establish the exact 
relations of phenomena, because they neglected to a great extent 
experiment and analysis of phenomena, and did not form definite 
and distinct ideas for each class of facts, still their general systems 
and cosmogonies were based upon observation of nature, and were 
partial expressions of great philosophic laws. Thus the reference 
of all motion and of all life to the light and heat of the sun, was 
without doubt founded upon the actual observation of the relations 
of the sun to plants and animals, and corresponds to the teachings 
of modern science, that the Creator has constituted the sun the 
source of motion, sensation, and life upon our globe. 

Modern science differs from ancient philosophy, in that it pene- 
trates beyond general views, decomposes the phenomena into its 
component facts, and points out the separate forces of the sun and 
terrestrial masses, and the relations of these forces, to each other 
and to the different forms of matter, inanimate and animate. 

In the history of the correlation of the physical forces, we have 



MALARIAL FEVER. 



27 



a history of the origin and development of the different depart- 
ments of physical and chemical science. 

In mechanics and astronomy, the establishment by Archimedes 
of the doctrine of the lever and some important properties of the 
centre of gravity, and the fundamental propositions of hydrostatics 
— the observation of the most striking phenomena — the formation 
of the notion of a year and month, and the fixation of the year and 
month and of the seasons — the invention of lunisolar years — the 
observation of the most general phenomena presented by the con- 
stellations and planets — the distribution of the places and motions 
of the heavenly bodies by means of a celestial sphere with imaginary 
lines drawn upon it — the promulgation of the doctrine of the globu- 
lar form of the earth by Anaximander, and the demonstration of 
this doctrine by Aristotle — the erection of the dial by Anaximenes 
and Anaximander — the attempt of Aristarchus to measure the dis- 
tance of the sun as compared with that of the moon — the establish- 
ment of the theory of epicycles and eccentrics by Hipparchus — the 
exposition of the theory of epicycles and eccentrics and of the 
observations and calculations which were employed in order to 
apply this theory to the sun, moon, and planets, and the discovery of 
evection by Ptolemy — the formal promulgation of the heliocentric 
theory by Copernicus — the application of the telescope to the 
examination of the heavenly bodies, the discovery of the satellites 
of Jupiter and of the ring of Saturn, and the verification of the 
Copernican theory with regard to the motion of Yenus by Galileo 
— the establishment by Kepler of numerical and geometrical laws 
connecting the distances, times, forces and velocities of the bodies 
which revolve about the central sun — the revival of the idea of 
pressure and the demonstration of the equilibrium of oblique forces, 
which includes the principle of the composition of statical forces 
by Stevinus — the establishment of the first law of motion (a body 
acted on by one force will move forever in a straight line with 
uniform velocity), the application in mechanical science of the 
notion of accelerating force, the establishment of the second law of 
motion (curvilinear motions), and of the principle of virtual vela- 
cities, and of the third law of motion, by Galileo — the confirmation^ 
of the laws of falling bodies, by the experiments and reasonings, of" 
Gassendi, Fermat, Riccioli, and Grimaldi — the labors, experiments^, 
reasonings and generalizations of Bacon, Descartes,^ Castelli, Huy- 
ghens, Hooke, Halley, Mersenne, Bernoulli, Hermann, Leibnitz^ 
Euler, Clairaut, D'Alembert, Lagrange, Gr'assendk Borelli, and otkej: 



28 



OBSEEVATIONS ON 



philosophers : all prepared the way for the development of those 
facts and fixed relations or laws, which formed the great Newtonian 
induction of nniversal gravitation, expressive of the truth that 
every particle of matter in all times, places, and circumstances is 
definitely related to every other particle of matter in the universe, 
by one common law of attraction, which must be pronounced, in 
whatever light it be viewed, whether in the immensity of the 
knowledge and labor which it involved, or the extent and bearing 
of the truth which it discloses, as the greatest scientific discovery, 
as a law which in generality and profundity and magnificence 
stands without a rival and without even a comparison. Whilst 
the facts which most nearly concerned Newton in the establish- 
ment of the law of gravitation, were the facts of the planetary 
motions as established by Kepler, and of the moon's motions as 
given by Tycho Brahe and Horrox, it is nevertheless true that the 
facts included in this law had been accumulating from the very 
foundation of astronomy, because it included every fact, discovery, 
and law, and included in one vast magnificent generalization the 
immense detail of astronomical science. 

In optics, the experiments, labors and reasonings of Seneca, 
Ptolemy, Archimedes, Euclid, Alhazen, Yitello, Snell, Gregory, 
Descartes, De Dominis, Newton, Huyghens, Grimaldi, Biot, Arago, 
Hooke, Young, Fresnel, Brewster, and others, have resulted in the 
establishment of the undulatory theory, which in its simplicity 
and universality bears the same relation to optics that the law of 
gravitation bears to astronomy. Whether we consider light as an 
undulation of a thin all-pervading ether, or of ordinary matter, 
the conclusion is the same, that it is a peculiar kind of motion or 
mode of force, and as such bears a definite relation to the other 
modes of force. Thus Professor Faraday has established the exist- 
ence of a relation between light and magnetism, and the relations 
of heat and light have been observed and studied by many inves- 
tigators, and modern investigations have demonstrated that an 
intimate relation exists between light and chemical afi^inity. 

In acoustics, the labors and discoveries of Pythagoras, Mersenne, 
Newton, Taylor, Bernoulli, D'Alembert, Euler, Lagrange, Laplace, 
Poisson, and others, have established the undulating theory of 
sound. According to this theory sound is a vibration or motion 
of ordinary matter, the character of which is dependent upon the 
number and arrangement of the atoms. 



MALAEIAL FEVER. 



29 



In tberraotics the theory of Bacon/ Locke,^ and others, that heat 
is motion, has been confirmed, enlarged, and extended to the 
varied phenomena of heat, by the experiments, observations, and 
reasoning of Kumford,^ I^avy," Leslie,^ Dalong,^ Clausius,^ Mayer,^ 
Magnus,^ Holtzmann, Regnault,^° Rankine, Thompson, Joule,^^ and 
others/^ 

* " From the instances taken collectively, as well as singly, tlie nature whose 
limit is heat appears to be motion. * * p. 161. 

" What we have said with regard to motion must be thus understood when 
taken as the genus of heat ; it must not be tliought that heat generates motion, or 
motion heat (though in some respects this be true) ; but the very essence of heat, 
or the substantial self of heat, is motion and nothing else, limited, however, by 
certain differences," p. 165. 

" The form or true definition of heat (considered relatively to the universe and 
not to the sense) is briefly thus : heat is an expansive motion restrained, and 
striving to exert itself in the smaller particles. The expansion is modified by its 
tendency to rise through expanding towards the exterior ; and the effort is modified 
by its not being sluggish, but active and somewhat violent. With regard to the 
operative definition, the matter is the same. If you are able to excite a dilatory 
or expansive motion in any material body, and so to repress that motion and force 
it on itself as not to allow the expansion to proceed equally, but only to be partially 
exerted and partially repressed, you will, beyond all doubt, produce heat ; without 
any consideration whether the body be of earth (or elementary, as they term it), 
or imbued with celestial influence, luminous or opaque, or dense, locally expanded, 
or contained within the bounds of its first dimensions, verging to dissolution, or 
remaining fixed, animal, vegetable, or mineral, water, or oil, or air, or any other 
substance whatever susceptible of such motion. Sensible heat is the same, but 
considered relatively to the senses," p. 171. — Novum Organum, or True Sugges- 
tions for the Interpretation of Nature, by Francis Lord Verulam. London, William 
Pickering, 1850. 

2 " Heat is a very brisk agitation of the insensible parts of the object, which 
produces in us that sensation, from whence we denominate the object hot ; so what 
in our own sensation is heat, in the object is nothing but motion." — John Locke. 

3 The first approximate numerical determination of the connection between heat 
and mechanical force (the mechanical equivalent of heat) was made by Count 
Rumford. His experiments had for their object the determination of the relation 
existing between the force and time expended in boring a brass cylinder, and the 
amount of heat developed by the friction. 

" It appears to me," Count Rumford remarks, " entirely difficult, if not quite 
impossible to form any direct idea of anything capable of being excited and 
communicated in the manner the heat was excited and communicated in these 
experiments, except it be motion." One of the most important points in his 
account of these experiments, is the estimate of the quantity of mechanical force 
required to produce a certain amount of heat. According to Count Rumford, the 
heat required to raise a pound of water lo F. is equivalent to a force represented 
by 1034 foot-pounds. This estimate is too high, because no account was taken of 
the heat dissipated during the experiment. — "An Inquiry concerning the Power 



so 



OBSEEVATIONS ON 



of Heat wliich is excited hy Friction," by Count Rumford, PJiil. Trans., vol. 
Ixxxviii., 1798 ; PhiJ. Trans, abridged, vol. xviii. p. 286. 

■* Sir Humplirej Davj communicated a paper to Dr. Beddoe's West County Con- 
tributions, entitled " Researches on Heat, Light, and Respiration," in which, he 
confirmed the views of Count Rumford, by melting two pieces of ice, rubbed against 
each other in the vacuum of an air-pump, which was kept below the freezing point. 
From this experiment Davy drew the inference that "the immediate cause of the 
phenomena of heat is motion, and the laws of its communication the same as the 
laws of the communication of motion." — See Elements of Chemical Philosophy, p. 94. 

^ Experimental Inquiry into the Nature and Propagation of Heat. London, 1804. 

^ Tlie researches of Dulong on the specific heat of elastic fluids established the 
fact that " equal volumes of all the elastic fluids taken at the same temperature 
and under the same pressure, being compressed or dilated suddenly to the same 
fraction of their volume, disengage or absorb the same absolute quantity of heat." 
Mimoires de VAcademie des Sciences, t. x. p. 188. This law, established by the 
researches of Dulong, is of the greatest importance in the development of the 
theory of heat, because it proves that the calorific eff'ect is under certain conditions 
proportional to the force expended. 

' " Ueber die bewegende Ki-aft der Warme," Fogg. Ann. Ixxix. 394. Ueber die 
Art der Bewegung welche wir Warme nennen, von R. Clausius, Fogg. Ann. c. 353. 
On the Application of the Mechanical Theory of Heat to the Steam-Engine, by R. 
Clausius. The American Journal of Science and Arts, vol. xxii. p. 360 ; vol. 
xxxii. p. 25. 

^ Experiment on the Evolution of Heat by Fluid Friction. Annalen of Woehler 
and Liebig, May, 1842. 

9 " Experiments on the Expansive Force of Steam," Poggendor3"'s Annalen, No. 2, 
for 1844 ; see Trans, in Taylor's Scientific Memoirs, vol. iv. p. 218. On the Force 
Requisite for the Production of Vapors, ibid., No. 2. 

1° " On the Elastic Forces of Aqueous Vapor," Annales de Chimie et de Physique, 
July, 1844 ; Taylor's Scientific Memoirs, vol. iv. p, 559. Hygrometrical Researches, 
Comptes Rendus, t. xx. pp. 1127 and 1220, April, 1845. Taylor's Scientific Me- 
moirs, vol. iv. p. 606. Phil. Mag., vol. xx. p. 111. 

" In 1843, Joule showed that the heat evolved by magneto-electricity is propor- 
tional to the force absorbed ; and that the force of the electro-magnetic engine is 
derived from the force of chemical affinity in the battery, a force which otherwise 
would be evolved as heat ; from these facts he announced that the quantity of heat 
capable of increasing the temperature of a pound of water by 1° F. equals and 
may be converted into a mechanical force capable of raising 838 pounds to the 
perpendicular height of one foot. — Phil. Mag., vol. xxiii. p. 441. 

In a subsequent paper, read before the Royal Society in 1844, Joule showed that 
the heat absorbed and evolved by the rarification and condensation of air is pro- 
portional to the force evolved and absorbed in these operations ; and the quanti- 
tative relation between force and heat, deduced from these experiments, is almost 
identical with that derived from the electro-magnetic experiments. — Phil. Mag., 
vol. xxvi. pp. 375 — 379. 

In 1843, Joule announced that heat is evolved by the passage of water through 
narrow tubes. — Phil. Mag., vol. xxiii. p. 442; xxvii. p. 205 ; xxxi, p. 173. 

In an article On the Mechanical Equivalent of Heat," published in the Philo- 
sophical Transactions of the Royal Society, part 1, 1850, p. 61. Joule announced as 
the results of an extended series of experiments : — 



MALAEIAL FEVER. 



81 



Yolta's immortal discovery demonstrated the relation between 
electrical and chemical phenomena ; the decomposition of water by 
Nicholson, in 1800, revealed the chemical energy of electricity, and 
constituted the starting point of electro-chemical resear^ch ; the 
brilliant discoveries of Davy^ demonstrated the close relation, if 
not the identity of chemical af&nity and electricity ; the labors of 
Becquerel established the synthetical influence of electricity; the 
profound and extensive researches of Faraday,^ following up the 

1. That the quantity of heat produced by the friction of bodies, whether solid or 
liquid, is always proportional to the quantity of force expended. 

2. That the quantity of heat capable of increasing the temperature of a pound 
of water (weighed in vacuo, taken at between 55 and 60^) by lo F. requires for its 
evolution the expenditure of a mechanical force represented by the fall of 772 
pounds through the space of one foot. 

'2 Memoirs on the Free Transmission of Radiant Heat through different Solid and 
Liquid Bodies, by M. Melloni, Taylor's Scientific Memoirs, vol. i. pp. 1 — 74, p. 325, 
p. 388. The Mathematical Theory of Heat, by S. D. Poisson, Aunales de Chimie 
et de Physique, "vol. lix. p. 71, et seq. See Analysis, in Taylor's Scientific Memoirs, 
vol. i. p. 122. Memoir on the Motive Power of Heat, by E. Clapeyron, Taylor's 
Scientific Memoirs, vol. i. p. 347. 

Kupffer, by comparing the expansion which a metal wire suffers by heat with 
the elongation produced by stretching it with a given weight, found that the heat 
necessary to raise a pound of water lo F. is equivalent to 661 foot-pounds. Phil. 
Mag. [4], xli. 393. Kronig on the " Fundamental Principles of a Theory of Gases," 
Pogg. Ann., xcix. 315. "Investigations on Radiant Heat," by H. Knoblauch, 
Taylor's Scientific Memoirs, vol. v. 188 — 383. " On the Heat and Elasticity of 
Gases and Vapors, and on the Principles of the Theory of Steam-Engines, by C. 
Holtzmann, Manheim, 1845. See also Taylor's Scientific Memoirs, vol. iv. p. 189. 



' In September, 1800, Sir Humphrey Davy published his first paper, describing 
experiments similar to those of Nicholson and Carlisle on the decomposition of 
water. — Nicholson^ s Journal, 4to. iv. 275. 

In 1802, Davy conjectured that in all cases of chemical decomposition the 
elements might be related to each other as electrically positive and negative, and 
in 18^6 attempted the solution of this question, and after referring to his 
experiments of 1800, 1801, and 1802, and to a number of new facts, which showed 
that oxygen, alkalies, and acids, and oxidizable and noble metals, were in electrical 
relations of positive and negative, he drew the conclusion, " that the combinations 
and decompositions by electricity were referable to the law of electrical attractions 
and repulsions," and advanced the hypothesis " that chemical and electrical 
attractions were produced by the same cause, acting in the one case on particles, 
in the other on masses ; and that the same property, under different modifications, 
was the cause of all the phenomena exhibited by different voltaic combinations." 
—Phil. Trans., 1826, p. 389. 

^ " On the Induction of Electric Currents ; the Evolution of Electricity from 
Magnetism ; a New Electrical Condition of Matter ; Arago's Magnetic Phenomena." 
Phil. Trans., 1831. "Terrestrial Magneto-Electric Induction ; Force and Direction 



82 OBSERVATIONS ON 

discoveries of Oersted, Davy, Arago, and Schweigger, demonstrated 
the identity of the chemical, electrical, and magnetic forces, and led 
this great philosopher to advance the idea that the so-called im- 
ponderable bodies are merely the exponents of different forms of 
force. 

The researches of Petit,^ in 1722, on the effect of light upon the 
crystallization of saltpetre and sal-ammoniac, and the analysis of 
the action and demonstration of the chemical influences of the rays 
of light, by Charles William Scheele,^ confirmed and extended by 
the researches of Senebier,^ Count Eumford,^ Meese,^ Priestley,^ 

of Magneto-Electric Induction," Bakerian Lecture, Jan. 12, 1831. Identity of 
Electricities derived from different Sources ; Relation by Measure of Common and 
Voltaic Electricity, 1833. Electro-Chemical Decomposition, 1833 and 1834. Na- 
ture of tlie Electric Force or Forces ; Relation of tlie Electric and Magnetic Forces ; 
the Current its Forces, 1838. On the Source of Power in the Voltaic Pile, 1840. 
On the Electricity Evolved by the Friction of Water and Steam against other Bodies, 
1840. On the Magnetization of Light and the Illumination of Magnetic Lines of 
Force, 1845. On New Magnetic Actions, and on the Magnetic Condition of all Mat- 
ter, 1845. On the Crystalline Polarity of Bismuth (and other bodies), and on its 
relation to the Magnetic form of Force, 1850. On the possible relation of Gravity 
and Electricity, 1850. On the Magnetic and Diamagnetic Condition of Bodies, 1850. 

For these and many other papers by Professor Michael Faraday, see Philoso- 
phical Transactions for 1831 — 1852. These papers have been collected and pub- 
lished in three volumes — vol. i., 1849, sec. ed. ; vol. ii., 1844, first ed. ; vol. iii., 
1855. In his Bakerian Lecture for 1845, Professor Farraday stated his views of 
the relations of the forms of force, thus : — 

" I have long held an opinion, almost amounting to conviction, in common with 
many other lovers of natural knowledge, that the various forms under which the 
forces of matter are made manifest have one common origin ; or, in other words, 
are so directly related and mutually dependent that they are convertible, as it 
were, into one another, and possess equivalents of power in their action. In modern 
times the proofs of their convertibility have been accumulated to a very consider- 
able extent, and a commencement made of the determination of the equivalent 
forces." 

• " Sur la Vegetation des Sels," Mem. de Paris, 1722. 

2 Scheele, Traite de I'Air et du Feu. 

^ Senebier sur la Lumiere, tom. iii. p. 199. 
" On the Propagation of Heat in Fluids," Phil. Trans. " An Inquiry concerning 
the Chemical Properties that have been attributed to Light," Phil. Trans., 1798. 

5 B. C. Meese, in 1775, first published experiments upon the influence of light 
on plants. 

^ In 1779, Dr. Priestley determined the problem of vegetable respiration, and 
showed that carbonic acid was absorbed by the plant, that under the influence of 
light it was decomposed and its oxygen liberated. Experiments and Observations 
on Diflferent Kinds of Airs and other Branches of Natural Philosophy, Birmingham, 
1790. See also Senebier, Experiences sur I'Action de la Lumiere Solaire dans la 
Vegetation, Paris, 1788. 



MALAKIAL FEVER. 



83 



4 

Ingeuhousz,' Saussure,^ Kitter,^ Wollaston,'' Young,^ Yogel,® 
Herscliel/ Seebeck,^ Gay-Lussac, Thenard, Berard, Wedgwood,^ 
Niepce, Daguerre,^" and Draper," have resulted in the establish- 
ment of the complex nature of the sunbeam, and the demonstration 
of the relations of light, heat, chemical affinity, and animal and 
vegetable life. 

The names which we have mentioned by no means form a 
complete list of those who have assisted, by their observations, 
experiments, reasonings, and teachings, in the establishment and 
promulgation of the doctrine of the mutual relations of the physical 
and chemical forces. 

In 1808, Oken'^ affirmed that "light could be nothing but a polar 
tension of the aether, evoked by a certain body in antagonism with 
the planets ; and that the heat was none other than the motion of 
this sdther ;" and in his " Physiophilosophy"^^ not only points out, 

' "Experiences sur les Vegetaux," PMl. Trans., 1782. 

2 " Recherclies Chimiques sur la Vegetation," Annales de Chimie, vol. i. 

^ Gehlen, Journal der Chem., vol. vi. 

* Philosophical Transactions, 1802, p. 379. 

5 Phil. Trans., 1804. 

6 Annales de Chimie, vol. Ixxv. 

' Transactions of the Royal Society of London, 1800. 
^ Philosophical Magazine, vol. vii., 2d ser., p. 462. 

9 An Account of a Method of Copying Paintings upon Glass, and of making 
Profiles by the Agency of Light upon Nitrate of Silver, with Observations, by H. 
Davy, 1802. 

'° History and Practice of Photogenic Drawing, by M. Daguerre. translated from 
the original by T. S. Memos, LL. D. London, 1839. 
" Philos. Mag., Sept., 1841. 

'2 Erste Ideen Zur Tlieorie des Lichts, der Finsterniss der Farden und der Warme, 
Jena, bey Frommann, 1808. 

'3 " Magnetism and electrism are correlated, as iron and sulphur, as gravity and 
light, as centre and periphery. The same spirit, which, when ruling in the dark, 
exhibits itself as magnetic, is manifested when it has attained to light in sulphur 
as electrical. Magnetism is only the electrical identified. We may, therefore, 
speak of idiomagnetic metals as well as idioelectric bodies. Magnetism, therefore, 
stands in opposition to electrism ; they mutually change or annihilate each other, 
p. 167. * * Chemism is related to magnetism as salt is to metal, as the sedi- 
mentary to the primary periods. The whole sedimentary period is a product of 
chemism, as the whole primary period is the product of magnetism." ^ * 

Magnetism and chemism are thus the creating agents for the solid nucleus of 
the earth, and through both it is completed. The process of earth formation is 
magneto-electrism. Regarding the earth as an entire crystal, magnetism is the 
determinant of its polar axis and polar radii, while chemism is the same in respect 
to its integral parts. All terrestrial action is an interchange of these two functions 
or souls, which are none other than the living gravity, and the living light upon 



84: 



OBSERVATIONS ON 



but bases mucli of his theory of the evolution and order of the 
world upon the mutual relations of gravity, light, electricity, mag- 
netism, heat, and chemical action. 

Carnot, in 1824, in his researches upon heat, attempted to esta- 
blish the relations of the physical forces. 

Lardner Yanuxem^ (an American), in the year 1827, published a 
work, in which he aflS.rmed that caloric, light, electricity, and mag- 
netism are convertible one into another, and are but different states 
of one kind of repulsive matter. 

In 1833, Dr. Metcalfe, in an essay entitled a "New Theory of 
Terrestrial Magnetism"^ (subsequently expanded^ into his magnifi- 
cent work on caloric), traced the most striking analogies of caloric 
and electricity, and endeavored to show that they are radically the 
same subtle, imponderable, and all-pervading element, and that its 
unequal distribution through nature is the cause of all the various 
forces and attractions of ponderable matter with which man is 
acquainted. 

the planet. The electricity, like the heat, only maintains them in eternal tension 
or extension. 

Chemism is the process of space, density, quiescent heat, therefore the latent 
heat, or the temperature, must change in every chemical process. 

Chemism is related to magnetism as heat to gravity, to electricity like as to 
light. 

Crystallization is point, magnetism line, electrism surface, chemism cube. Ele- 
ments of Physiophilosophy, by Lorenz Oken, M. D. ; translated for the Ray Society 
from the German, by Alfred Tulk, pp. 176—177. London, 1847. 

Coleridge maintained that electricity, galvanism, and magnetism, are the funda- 
mental principles of action in nature, and that " a power acting exclusively in 
length is (wherever it be found) magnetism ; that a power which acts both in 
length and breadth, and only in length and breadth, is (wherever it be found) 
electricity; and, finally, that a power which, together with length and breadth, 
includes depth likewise, is (wherever it be found) constructive agency." — Hints 
towards the Formation of a more Comprehensive Theory of Life, by S. T. Coleridge. 
Philadelphia, 1848. 

' An Essay on the Ultimate Principles of Chemistry, Natural Philosophy, and 
Physiology, by Lardner Vanuxem. Philadelphia, 1827. 

2 Caloric, electricity, and galvanism have hitherto constituted a separate and 
distinct triad of imponderables, perfectly incomprehensible ; all the phenomena of 
which are quite intelligible, if we refer them to the agency of one grand, jDrimary, 
universal element," p. 27. 

^ This article was extended, published in a series of articles in the Knicker- 
bocker Magazine for 1834 — 5, and finally expanded into that great work, which 
will ever remain as one of the noblest monuments of American learning and phi- 
losophy. Caloric, its Mechanical, Chemical, and Vital Agencies in the Phenomena 
of Nature, by Samuel L. Metcalfe, M. D. London : William Pickering, 1843. 



MALARIAL FEVER. 



85 



Dr. Samuel Jackson/ in his Introductory Lecture for 1837, 
asserted that " physical phenomena, according to the class to which 
they belong, are referred to a few simple laws, as gravity, caloric, 
affinity, galvanism, electro-magnetism, all of which, it can now be 
scarcely doubted, are manifestations of one great force." This learned 
teacher and philosopher has for one quarter of a century taught 
from his chair in the University of Pennsylvania, not only the 
correlation of the physical forces, but also the mutual connection 
of the vital and physical forces, and demonstrated before thousands 
of medical students and physicians "that the same causes and 
actions which in inorganic bodies constitute physics, in organic 
bodies constitute physiology, or, as it may be more aptly termed, 
organic physics." 

Mr. Grove,^ in a Lecture delivered at the London Institution, on 
the 19th of January, 1842, showed that "light, heat, electricity, 
magnetism, motion, and chemical affinity, are all convertible mate- 
rial affections ; assuming any one as a cause, one of the others will 
be the effect. Thus, heat may be said to produce electricity, elec- 
tricity to produce heat ; magnetism to produce electricity, electricity 
magnetism; and so of the rest." 

In this same year, J. E. Mayer,^ of Heilbronn, saw truly and 
expressed correctly this general law; and in 1813, Colding pre- 
sented a memoir to the Academy of Copenhagen, in which the 
same law found utterance. 

Dr. H. Helmholtz^ read before the Society of Berlin, July, 1817, 

' In the year 1849, in a paper read at the meeting of the American Medical 
Association, held in Boston, Dr. Jackson announced the correlation of animal 
mechanic force and heat. 

For a condensed statement of the views of this philosopher, see his valuable 
" Introductory Essay on the Human Organism and its Forces, with Remarks on 
Dr. Lehmann's Doctrine of Vital Forces," by Samuel Jackson, M. D., Professor of 
the Institutes of Medicine in the University of Pennsylvania. — Lehmann^s Manual 
of Chemical Physiology, translated by J. Cheston Morris. Philadelphia, 1856. 

2 The Correlation of Physical Forces, by W. R. Grove, first ed., 1846 ; third ed., 
1855, London. 

2 Organic Movements in their Relations to Material Changes, 1845. See also 
Trastour's pamphlet — Caloric, Origin, Matter, and Law of the Universe, 1847. 
" Identities of Light and Heat, of Caloric and Electricity," by Dr. C. C. Cooper, 1857, 
British and Foreign Medical Review, article 18, Oct., 1844. Carpenter's Principles 
of Greneral and Comparative Physiology, 1841, p. 167. "On the Mutual Relations 
of the Vital and Physical Forces," by William B. Carpenter, M. D., Phil. Trans., 
June 20, 1850, part ii. p. 727. 

" On the Conservation of Force, a Physical Memoir," by Dr. H. Helmholtz (read 
before the Physical Society of Berlin, July 23, 1847, Berlin, by Reimer), see trans. 



86 



OBSERVATIONS ON 



a most profound, elaborate, and philosophic memoir on the " Con- 
servation of Force," based upon two maxims: — 

1. "That it is not possible, by any conditions whatever of natural 
bodies, to derive an unlimited amount of mechanical force. 

2. "All actions in nature can be ultimately referred to alter- 
nate attractive or repulsive forces, the intensity of which depends 
solely upon the distances between the points by which the forces 
are exerted." 

In this valuable memoir. Dr. Helmholtz refers natural phenomena 
back to unchangeable attractive and repulsive forces, whose inten- 
sity depends solely upon the distance ; and establishes, by copious 
illustrations and mathematical demonstrations, the interaction and 
indestructibility of the forces of nature.^ 

Organized animated bodies are composed of inorganic elements, 
and are governed by all the laws and phenomena of inorganic 
bodies, and are absolutely dependent^ for their existence upon 

in Taylor's Scientific Memoirs, vol. vi. pp. 114 — 162. " On tlie Interaction of Natural 
Forces," bj H. Helmholtz, Professor in the University of Bonn, translated by John 
Tyndall, Phil. Mag., fourth series, vol. ii. p. 487. See also the American Journal 
of Science and Art, vol. xxiv., September, 1857, pp. 189 — 216. 

^ See also " Observations and Experiments on the Theory of the Identity of the 
Agents which produce Light and Radiant Heat," by M. Melloni, Annales de Chimie 
et de Physique, vol. i. p. 418. Taylor's Scientific Memoirs, vol. i. p. 388. " On the 
Chemical Effects of Electric Currents of Low Degree in Crystallization," by M. 
Becquerel, Becquerel's Traite de Electricite et du Magnetisme, vol. iii. p. 287. 
" On the Application of Electro-Magnetism to the Movement of Machines," by M. H. 
Jacobi, Potsdam, 1835, Taylor's Scientific Memoirs, vol. i. p. 503 ; vol. ii. p. 1. 
" Experiments of Joule determining the Relations of Heat and Electricity," Phil. 
Mag., vol. xix. p. 275 ; to Chemical Affinity, vol. xx. p. Ill ; vol. xxiii. p. 441. 
" The Galvanic Circuit Investigated Mathematically," by Dr. Gr. S. Ohm, Taylor's 
Scientific Memoirs, vol. ii. p. 401. " General Propositions relating to Attractive 
and Repulsive Forces acting in Inverse Ratio of the Square of the Distance," by C. 
F. Gauss, trans, in Taylor's Scientific Memoirs, vol. iii. p. 153. " On the Relation 
of Magnetism to Diamagnetism," by M. Pliicker, Poggen. Ann., Oct., 1847 ; trans, 
in Taylor's Scientific Memoirs, vol. v. p. 376. *' On the Measurement of Electro- 
Dynamic Forces," by W. Weber, Poggen. Ann., January, 1848 ; Taylor's Scientific 
Memoirs, vol. v. p. 489. " On the Mechanical Equivalent of an Electric Discharge, 
and the Heating of the Conducting Wire which accompanies it," by R. Clausius, 
Pogg. Ann., 1852; Taylor's Scientific Memoirs, vol. vi. p. 1. "On the Work per- 
formed and the Heat generated in a Conductor by a Stationary Current," by R. 
Clausius, Pog. An., vol. Ixxxvii. p. 415 ; Taylor's Scientific Memoirs, vol. vi. p. 200. 
Philosophy of the Mechanics of Nature, by Z. Allen, New York, 1852. 

2 Inorganic bodies are wholly independent of the organic, are less complex in 
structure, their phenomena are more simple, and the laws of their existence more 
universal. Thus, the bodies oxygen and carbon are widely difi'used throughout 
nature, and their existence is wholly independent of that of any other bodies. 



MALAEIAL FEVER. 



37 



inorganic bodies ; they have, however, a new set of phenomena, 
dependent upon the vital force ; and in animals we have another 
set of phenomena, dependent upon the existence of the nervous 
system and intellectual faculties ; and in man we have another set 
of phenomena, dependent upon the combination of the intellectual 
and moral faculties. 

Inorganic bodies, with their properties, form the necessary con- 
ditions for the existence of plants and animals, just as the properties 
of cohesion and gravitation form the essential conditions for the 
existence of the universe, in its present arrangement ; the pheno- 
mena of living beings, plants and animals, are, therefore, more 
complicated and less general than those of inorganic inanimate 
bodies; and it is evident that to understand the phenomena of 
living beings, and their relations with the universe, we must com- 
prehend the phenomena and relations of all inorganic bodies. 

The relative proportions of the inorganic elements entering into 
the constitution of plants and animals, correspond, in a measure, 
to the relative quantities of these elements in the exterior world. 
Whilst the majority of the sixty-two simple bodies, with their 
compounds, exist only in small quantities, and enter into but few 
combinations, and exert but little influence upon the phenomena 
of organized bodies, the elements composing the great mass of our 
globe are the very elements which are essential to the formation of 
the structures and manifestation of the forces of animated beings. 

Water, which covers two-thirds of the surface of our globe, 
and is distributed throughout the atmosphere and soil, exists in 
similar proportions in the structures of plants and animals. We 
have seen that water is the great medium of chemical change in 
the inorganic world — that under the action of heat and gravita- 
tion, a great circulation of water is carried on through the atmo- 
sphere, and over the surface of the continents .and islands, which 
disintegrates and wears down the solid rocks, dissolves and washes 
away the impurities of the atmosphere and land. An analogous 
lesser circulation of water, whose existence depends upon the great 
circulation in the inorganic world, is carried on unceasingly through 
the textures of plants and animals ; and water in the organized 
world, as in the inorganic, is the great medium of change, and the 

Plants and animals are composed in large measure of tliese two bodies, in com- 
bination with hydrogen and nitrogen. Without tliese elements, with their peculiar 
properties and arrangements, plants and animals could not exist. 



38 



OBSERVATIONS ON 



great agent in the removal of disintegrated, chemically altered, 
offending substances. The amount of water required annually for 
the circulation through the textures, the distribution of the nutri- 
tive materials, and the removal of the waste, useless products of the 
billion inhabitants of the earth, is, at the lowest calculation, 1,500 
billion pounds ; while 3,000 billion pounds are required for the 
accomplishment of similar offices in the animal kingdom ; and the 
vegetable kingdom, at the lowest calculation, requires annually 
9,288,000,000,000,000 pounds, or 4,644 billion tons of water. 

Eight-ninths of all the water, one-fifth of the great ocean of 
gaseous matter, and from one-half to two-thirds of the solid crust 
of our globe, are composed of oxygen, in combination with hydro- 
gen, silicum, aluminum, calcium, sodium, potassium, magnesium, 
iron, and carbon. In the inorganic world oxygen is the great 
purifier of earth, air, and sea — the great element of combustion — 
the great element of chemical change — which, excited by the forces 
of the sun, works unceasingly. Oxygen constitutes from two-thirds 
to four-fifths of the structures of plants and animals, and immense 
quantities are used in the chemical changes of the elements during 
the construction and disintegration of the tissues and the develop- 
ment of the forces ; the human race alone annually consumes 800 
billion pounds of oxygen, in addition to the 1,322 billion pounds 
contained in the water circulating annually through the textures. 
The oxygen enters into combination with the elements of the food, 
and of the tissues and organs — during these ceaseless chemical 
changes the integrity of the structures and the individuality of 
animals are preserved, and the forces which work their machinery 
generated. The structures of plants and animals are composed 
chiefly of three gases and one solid ; they are dependent, however, 
upon the soil for certain salts of lime, soda, potassa, silica, and iron. 
These salts, although existing in small amount, are absolutely ne- j 
cessary for the existence of plants and animals; every soil which ' 
does not contain these salts in an available form for plants will 
not support the higher species necessary for the elaboration from 
inorganic matter, of compounds necessary for the structures, and 
chemical changes and development of the forces of the most highly 
developed animals. The absence of a single inorganic constituent 
from the food of man and the higher animals, will be attended by 
derangement of the structures, aberration of the forces, and, finally, 
death. The researches of chemists, physiologists, and pathologists, 



MALARIAL FEVER. 



89 



have shown that more than two-thirds of the sixtj-two simple 
elements, with their various compounds, so far from entering into 
the constitution of plants and animals, are dangerous poisons, 
capable, in the smallest quantities, of producing death. This com- 
parison of the mineral constituents of plants and animals with the 
constituents of the crust of our globe, develops such a close corre- 
spondence that the conviction is forced upon us, that not one of the 
essential constituents of the crust of our globe could be altered, 
either in quantity, distribution, or chemical relations, without the 
destruction of animals and vegetables. What would have been 
the result if arsenic had been as widely distributed as iron ? What 
would have been the result if the chlorine of the sea-water and 
crust of our globe had been united with mercury instead of with 
sodium ? Nor is this all; the very scarcity and poisonous proper- 
ties of these substances have exerted great influences upon the 
development of certain arts and sciences. 

Whilst inorganic bodies form the structures of plants and animals 
and retain all their physical and chemical properties and relations, 
whilst the circulation of matter in the organized world is carried on 
by the same forces as in the exterior inorganic world, and whilst 
there is no creation of matter or of force in the bodies of animated 
beings, it is, nevertheless, true that living beings have a new set of 
phenomena, and that their structures and phenomena are more 
complicated and less general than those of inorganic bodies. 

Without entering into an enumeration of all the distinctions be- 
tween inorganic bodies and animated beings, it may be stated that 
inorganic bodies are homogeneous in structure, and would remain 
forever at rest and unchanged, physically and chemically, unless 
acted upon by extraneous forces, and in inorganic compounds the 
biniary arrangement is pursued ; whilst, on the other hand, all 
vegetables, from the simple cell to the most highly developed, and 
all animals, from the simple cell animalcule to the complicated 
organism of man, have arisen from cells, and are composed of cells 
variously developed and grouped, so as to form organs, and systems 
of organs, and apparatus, capable of accomplishing definite results, 
when moved by the proper chemical and physical forces, and in 
organic compounds, four bodies, carbon, hydrogen, oxygen, and 
nitrogen, unite in varying proportions, forming an endless series 
of compounds. 

Amidst the unceasing chemical and physical changes of the ma- 
terials of organized beings, individuality of form is preserved and 



40 



OBSERVATIONS ON 



unity of action maintained. The development of a definite form 
from a formless mass, and ttie preservation of that form amidst 
unceasing chemical and physical changes, is the great characteristic 
of organized beings. 

As no force or combination of forces in the inorganic world can 
accomplish the development of a form from a formless mass, and 
the preservation of that form amidst unceasing chemical changes, 
the human mind, reasoning upon the axiom that every effect must 
have a cause, refers these effects to a special cause, called the vital 
force. It is true that no one has ever seen this force. We know 
it only by its effects. The same thing is true of all forces. Ko 
one has ever seen the force (the cause of the phenomena) of heat, 
light, electricity, or magnetism. We do not observe forces, but we 
infer their existence from their effects. The conclusion, then, that 
animals and plants are endowed with a force which inorganic bodies 
do not possess is logical. We can come to no other conclusion if 
we reason in accordance with the structure of our minds. If it be 
true that the human mind is the work, and even the reflection of 
the image of the Creator, who is himself Truth, we are confident 
that whenever our minds reason in rigid accordance with all the 
known facts, and their own structure, they must obtain the truth. 

In this view of the relations of organized and inorganic bodies, 
we do not attribute to the vital force any power to produce either 
chemical, or physical, or nervous forces. Its power is limited to a 
direction of the forces of matter, so that a form is developed from 
formless matter, maintained, and definite results accomplished, and 
unity of action preserved. All the movements in plants and ani- 
mals depend ultimately upon the chemical changes and physical 
properties of their elements, and upon the forces of the sun. With- 
out these forces the vital principle can accomplish nothing. 

According to this view the action of the vital principle, like that 
of the intelligence, is limited to a guidance and direction of the 
forces with which the Creator has endowed all matter. The action 
of the vital principle upon matter, like that of the intelligence, does 
not consist either in a creation of matter, or in a direct movement 
of matter independent of the forces of matter, but in the mere 
guidance and application of the forces of matter, so that definite 
forms are developed from formless matter, and definite results 
accomplished. 

According to this view the vital principle and the intelligence 
cannot create force any more than they can create matter. Their 



MALAEIAL FEVEK. 



41 



influence is limited to an excitement and application of the forces 
of matter. We judge of the influence of one just as we judge of 
the influence of the other. The complicated machine points to 
the existence of an intelligence distinct from matter, which has so 
applied the forces of one portion of matter that another portion 
has been moulded into definite shapes, and formed into definite 
apparatuses, capable of accomplishing definite results, when acted 
upon by forces generated and applied in the right manner. We 
infer the existence of the intellect by the results of its application 
of the forces of matter. In precisely the same manner do we infer 
the existence of the vital principle. 

The vital principle directs the forces resulting from the chemical 
changes of one part of matter, in such manner that surrounding 
matter is fashioned, moulded into definite forms and apparatuses, 
destined to accomplish definite results. This apparatus cannot 
be worked by the vital principle independent of chemical action, 
any more than a watch will run or any machine accomplish 
various mechanical effects without a supply of exterior force, or a 
steam-engine accomplish mechanical effects without the develop- 
ment of force by the chemical changes of matter, which has been 
elevated into a state of force (placed in a state capable of under- 
going chemical change) by the forces of the sun. 

In the living animals the forces resulting from the chemical 
changes are expended under the direction of the vital principle to 
accomplish : — 

1. The preparation and elevation of new materials into the place 
of that which has been chemically altered during the development 
of the forces. 

2. The removal of the products of the chemical changes, which 
are no longer fit to form the organized structures, and are no longer 
capable of undergoing the changes necessary for the development 
of the forces. 

3. The working of the apparatus which distributes the elements 
of secretion, and excretion, and force, expels the excretions and 
moves the body. 

In the living animal the rapidity of the chemical changes which 
develop the forces of the machinery, depend, first, upon the supply 
and distribution of materials capable of entering into the consti- 
tution of the organs, tissues, and apparatus ; secondly, upon the 
supply and distribution of materials capable of undergoing chemical 
change within and around the machinery, and thus generate the 
4 



42 



OBSERVATIONS OX 



forces in positions advantageous for their application : thirdly, upon 
the replacement of the chemically altered matter which once formed 
part of the apparatus (machinery) by new matter; fourthly, upon 
the removal of the products of chemical change, which derange 
chemical action — first, by occupying positions in the apparatus 
which should be occupied hj matter in a state of force, and not 
by matter which has lost the amount of force originally received 
from the sun; secondty, by inducing chemical changes in wrong 
positions in parts of the organism where the forces resulting from 
their chemical changes cannot be applied ; and, thirdly, by a direct 
poisonous effect upon the organs, tissues, and apparatus, especially 
upon the nervous system, which keeps up a communication between 
all parts of the system, and controls, in a great measure, the distri- 
bution of the elements of nutrition and chemical change, by con- 
trolling the action of the respiratory and circulatory apparatus. 
The supply and distribution of the materials of nutrition and che 
mical change depend, first, upon the perfection and action of the 
vegetable kingdom, and, secondly, upon the perfection and action 
of the animal, digestive, circulatory, and respiratory apparatus, 
related and co-ordinated by the nervous system. 

The study of the animal kingdom as a whole demonstrates that 
the perfection and action of the respiratory and circulatory systems 
may be taken as an index of not only the physical and chemical 
changes of the organized fluids and solids, but also of the develop- 
ment and perfection of the organs, and tissues, and apparatus, and 
of the activity and intelligence of animals. 

The action of the respiratory and circulatory apparatus, the co- 
ordination of this action with the action and wants of the muscular 
and nervous systems, and of all the organs, and tissues, and ap- 
paratus, is guided by the nervous system, in which a special force 
is generated — excited and guided by nervous force, but not carried 
on by nervous force, independent of chemical change. 

Chemical change in the organs and apparatus, and chemical 
change in the nervous systems, is the source not only of heat, but 
of muscular and nervous force, and of all the forces generated in 
the animal economy. 

All the acts called vital, and nervous, and muscular, by many 
physiologists, such as the contraction of the muscles, and the trans- 
mission of impressions to and from the nervous sensitive centres 
along the nerves, are due to the chemical changes of those ele- 
ments which have been separated from oxygen, and elevated into 



:malaeial feyee. 



43 



a state of force (capable of chemical change) by the forces of the 
sun, acting through special organs in the vegetable kingdom. There 
is a change of force in direction and mode of action, but there is no 
creation of force. 

The generation of any force — vital, nervous, chemical, or phy- 
sical, in the animal economy, independent of antecedent force, 
would destroy the great law upon which the stability of the uni- 
verse rests, that force is indestructible — would destroy the great 
law that action and reaction are equal. 

The vital force does not create any force, however feeble ; but, 
like the intellect, merely employs the forces with which the Creator 
has endowed matter, just as a master-workman employs the forces 
of men to act upon matter and construct an edifice. If the vital 
force be not analogous to intelligence, how does it come that all 
the organs and apparatus are developed upon a definite plan, 
adapted by structure and conformation to the medium in which the 
animal lives, and to all the physical forces ? 

The difference between vegetables and animals, and between the 
different species of each kingdom, depends not upon differences of 
forces, or of the elements of their structures, but upon the differ- 
ence of the development of the apparatus by which the physical 
and chemical forces are applied. Thus, vegetables are fixed to the 
soil, and their structures are all arranged, for the accomplishment 
of a definite purpose — the application of the forces of the sun to 
the grouping of the atoms of inorganic matter, and the products of 
the disintegration of the tissues of animals, in such a manner that 
they may not only form the tissues and organs of plants and ani- 
mals, but also that they may be capable of undergoing change, and 
of giving back the same amount of force which they had received 
from the sun. 

The arrangement of the atoms of the structures of animals, and 
the forces resulting from the chemical changes of these atoms, are 
resultants of the forces of the sun, acting through special organs of 
plants, and guided by the vital force of plants, so as to overcome 
the chemical affinities of certain elements, separate them, place 
them in a situation where they can again undergo chemical change, 
and give out the force originally expended by the sun in over- 
coming their chemical affinities. 

All matter upon the face of our globe tends continually to come 
to rest. This tendency is due to several causes, as the action of 
gravity, the limited amount of force with which matter is endowed. 



44 



OBSERVATIONS ON 



and the continued radiation of heat into space, and the loss of the 
forces of the elements by radiation during their chemical union. 
Without a continued supply of force all motion would cease, both 
in the inorganic and organic worlds. 

The great force which moves the crude sap of plants from the 
roots to the leaves, from cell to cell, in opposition to the force of 
gravity, is endosmose, which is itself dependent upon chemical 
actions, and the varying densities of the contents of the cells, both 
of which depend ultimately upon the forces of the sun. After the 
inorganic elements and moisture have been supplied, the luxuri 
ance and perfection of plants depend upon the intensity of the 
forces of the sun. 

The truth of this proposition may be established by a reference 
to the distribution of plants upon the surface of our globe, and 
upon mountains, which rise to a great height in tropical countries. 

Whilst in equinoctial and tropical countries, where a sufficient 
supply of moisture combines with the influence of heat and light, 
vegetation appears in all its magnitude and glory ; on the other 
hand, in polar regions, and upon the summits of lofty mountains, 
all the more complicated forms of vegetable existence disappear, 
and lichens and microscopic plants take the place of the majestic 
forests and impenetrable jungle. In the tropics the lowest orders 
of plants are comparatively rare ; whilst in the polar regions, and 
upon the summits of mountains, they form almost the entire vege- 
tation. 

The strength and activity of animals depend upon the develop- 
ment of the apparatus by which the elements for chemical change 
are distributed, and the forces resulting from these chemical changes 
applied, and a free communication between the different systems of 
organs kept up. The development of the apparatus depends upon 
the directive influence of the vital force. 

The truth of these propositions may be clearly demonstrated by 
a comparison of the phenomena and anatomical structures of the 
different species, genera, orders, and classes of animals. Thus, the 
sluggish, feeble, cold-blooded animal is such, not from any pecu- 
liarity of the elements or forces of its structures, but from the I 
imperfect development of the structures and apparatus by which j 
the elements of chemical change are distributed, and the forces t 
resulting from these changes applied. The forces of an animal • 
with imperfectly developed lungs and circulatory apparatus are ' 
necessarily feeble, because the apparatus for the introduction and ' 



MALARIAL FEVER. 



45 



distribution of the great agent of chemical change (oxygen) are 
defective in their action. 

In the animal, as in the plant, and as in the universe, there is no 
creation of force independent of the Creator. The geographical 
distribution of plants, and the relations of animals to the forces of 
the sun (surrounding temperature), demonstrate conclusively this 
proposition. The independence of higher animals of surrounding 
cold (absence of heat or force) is due solely to the fact that they 
can receive and distribute rapidly the materials necessary for the 
development of the physical, chemical, and nervous forces. As the 
external temperature diminishes, the internal chemical changes cor- 
respondingly increase. If, however, the external heat diminishes 
to a point at which the heat lost by radiation from the surface of 
the body of the living being is greater than that developed by 
the greatest possible combustion, the warm-blooded animal will 
be reduced to the condition of a sluggish cold-blooded animal, and 
finally lose all motion and life. The distinction, then, between cold 
and warm-blooded animals, drawn from their temperature and cor- 
responding forces, is relative and not absolute. 

As far, therij as the hiowledge of man extends^ the great law of the 
indestrudihility of force^ and the great laiu that action and reaction are 
equal, are applicable to all phenomena, inorganic and organic. 

Physical and chemical forces exist independently of the vital 
force ; the vital force, on the contrary, cannot exist and manifest 
its peculiar effects without matter and the physical and chemical 
forces; the acts of development, nutrition, secretion, and excretion, 
and propagation, which are peculiar to plants and animals, are 
resultants of the action of the physical and chemical forces upon 
matter, under the guidance of the vital force, which is incorporated 
with and presides over every molecule of living organized matter, 
and directs all its physical and chemical changes, so that amidst 
innumerable and unceasing changes the individuality of every 
organ, apparatus, and animal is preserved. 

As the germination and development of vegetables and animals, and 
the maintenance of their life actions, depend essentially upon the proper- 
ties of matter, upon the relations of matter to the sun and fixed stars, 
and upon the correlation of the vital, chemical, and physical forces, it 
is evident that the study of complicated, highly developed plants and 
animals involves the consideration of their origin, development, structure, 
and relations to exterior bodies — involves the consideration of the chemical 
and physical properties of the elements, and combination of elements 



46 



OBSEEYATIOXS OX 



entering into their constitution^ and the relations of the constituents of 
their hodies to the surrounding medium — involves the consideration of 
the relations of the vital, chemical, and physical forces, and intellectual 
and moral faculties — involves the consideration of the relations of ani- 
mated beings to the forces and arrangements of the sun, and 'planets, and 
fid:ed stars. 

The history of the origin, development, and distribution of plants 
and animals, as revealed by the records upon the solid rocks ; the 
geographical distribution of the plants upon the surface of our 
globe at the present time; the geographical distribution of animals, 
and the relations of animated existence to the surrounding medium 
and external forces as revealed in the correspondence of the internal 
structures and forces with the arrangements and chemical relations 
of the elements and the rapidity of the chemical changes, demon- 
strate that the most simply constructed plants and animals are more 
widely distributed over the surface of our globe, and the conditions 
of their existence more general and less complicated than the more 
highly developed plants and animals ; demonstrate that as we rise 
in the scale of animal and vegetable existence, the phenomena of 
life become more complex and less general, and the conditions of 
their existence more complicated and restricted.^ 

^ Tlie trutli of tliese propositions may be illustrated in a forcible manner by tbe 
relation of vegetable and animal existence to the distribution of the forces of the 
sun upon the surface of our globe. Thus, as a general rule, after the inorganic 
elements and moisture have been supplied, the luxuriance and perfection of plants 
depend upon the intensity of the forces of the sun. The more complicated and 
perfect the vegetable structures, the closer is their dependence upon the proper sup- 
j)ly and balance of the physical forces. The converse of this proposition is also 
true. The truth of these propositions may be established by references to the 
distribution of plants upon the surface of our globe, and upon mountains which 
rise to a great height in tropical countries. Whilst, in equinoctial countries, where 
a sufficient supply of moisture combines with the influence of heat and light, 
vegetation appears in all its magnitude and glory ; on the other hand, in polar 
regions, and upon the summits of lofty mountains, all the more complicated forms 
of vegetable existence disappear, and lichens and microscopic plants take the place 
of majestic forests and impenetrable jungles. In the tropics the lowest orders of 
plants are comparatively rare, whilst in polar regions and upon the summits of 
mountains they form almost the entire vegetation. The plants which first form 
upon barren rocks, and lava streams, and coral islands, are those of the most 
simple organization. The simply organized lichens covering the bald-granite rocks 
are familiar to every resident of a primitive region. Along the sides of Etna, 
Ischia, Vesuvius, and other volcanoes, lava streams are seen stretching in all 
directions, which have flowed down like rivers. These lava streams are of difi"erent 
ages, and many of them were formed within the memory of man. An investigation 



MALAEIAL FEVER. 



47 



An examination of the origin, development, structure, and 
relations of all vegetables and animals, commencing with the 

of these lava streams affords an opportunity of determining tlie gradual distribution 
of vegetables. Some are still naked, others liave only a few plants scattered here 
and there in hollows and crevices, and in others the decaying plants are forming 
a soil. According to the observations of Prof. J. F. Schow, the plants which first 
settle upon the naked lava, and form a soil for the more complex, are especially 
those lower and simply organized plants, called lichens. Certain succulent and 
fleshy plants, as the Indian fig (opimtia vulgaris), which are nourished chiefly by 
the carbonic acid and aqueous vapor of the open air, absorbed by the stem and 
leaves, are also amongst the earliest inhabitants of the lava streams. Geology also 
teaches that the lower orders of plants appeared first upon our globe. 

As the luxuriance and perfection of plants depend upon the temperature of the 
surrounding medium, and the intensity of the forces of the sun ; so also the per- 
fection of the nervous system, and of all the organs and apparatus, and the activity 
and intelligence of animals, correspond, in a great measure, to the rapidity of the 
physical and chemical changes going on in the molecules of their bodies, and to 
the relations of the physical, and chemical, and vital forces, and to the temperature 
which they are able to maintain, regardless of that of the surrounding medium. 

As the chemical changes become feeble, and the temperature of animals descends 
and becomes dependent upon that of the surrounding medium, they become more 
simple in their organization and mode of life, the conditions of their existence 
become less restricted, and they resemble closely the simple forms of vegetables, 
and in the twilight of existence we can scarcely distinguish between the lowest 
forms of plants and animals. 

If we examine the relations of the physical and chemical agents to the animal 
kingdom, we will find that the most simply constructed animals, many of which 
are devoid of a nervous system and special organs of sense, as the infusoria, are, 
as in the case of the simply organized plants, the most widely distributed over the 
face of our globe, and are at the same time far less dependent for their existence 
upon the temperature of the surrounding medium. 

Infusoria occur in immense numbers in every situation : in stagnant pools, in 
marshes, in mud of rivers, in peat earth, twenty feet below the surface ; in the 
structures and fluids of living animals and vegetables, in putrefying organic matter, 
in the bed and waters of the ocean, in snow, in ice, and in boiling springs. 

Sir John Ross, in the year 1840, picked up some brash ice of a brown yellow 
color in the Arctic regions, not far from Mount Erebus, which was supposed to con- 
tain aluminous matter, ejected in fine ashes from the volcano. Specimens were 
brought home in sealed glass vessels, and forwarded to M. Ehrenberg. 

This microscopist found the coloring matter to consist of myriads of infusoria, 
almost the whole of which reached Berlin in 1844, in a living state. Here we see 
that these microscopical animals, after having been frozen and thawed out, lived 
without food for four years. Certain species of these animalcules have been found 
living and propagating in boiling springs, and some of them have been observed to 
recover after drying in vacuo along with chloride of calcium and sulphuric acid for 
twenty-eight days, and after exposure to a heat of 2480. The infusorial animals 
were created at an early geologic period, and a large number of the fossil species, 
which compose the polirschifer and semi-opal of Bilin, are found at the present 
time living and propagating in the seas and oceans. The infusoria form a chain 



48 



OBSERVATIOXS ON 



simplest, and ending with the most complicated, leads us to the 
summit of the pyramid upon which stands man — governed by all 
the astronomical and chemical and physical laws of inorganic 
bodies, and comprehending within himself all organic nature — 
arising in common with plants and animals, from the organic cell, 
and like them, passing through various stages of development — 
endowed in common with all vegetables and animals, with vital 
force — possessing in common with all animals, and in contradis- 
tinction to vegetables, a nervous system endowed with special sen- 
sibilities, relating the intellectual faculties to the exterior world, 
and relating the various organs and apparatus to each other, in 
such a manner that, amidst an innumerable number of complex 
actions, unity and harmony result — an organism composed of in- 
organic elements, prepared and grouped into definite compounds 

connecting the organic life of distant ages of the earth, and demonstrating conclu- 
sively that the distribution of animals, and the power to survive physical changes, 
depends upon their development. 

The simpler the structures, the feebler the vital, nervous, and physical forces, 
the less complicated the conditions of existence. The gelatinous medusse (gelly 
fishes) occur in such vast numbers in the cold Greenland sea, that they impart an 
olive green color to the sea, rendering the water dark and opaque, in comparison 
with the ordinary cerulean hue. Cold-blooded vertebrate animals, although more 
highly organized than invertebrate animals, still show remarkable powers of 
enduring extremes of heat and cold without death. Fish may be frozen and again 
thawed out without a destruction of life. The rapidity with which the absence 
of heat is attended with loss of sensibility and death, is directly proportional to 
the development and perfection of vertebrate animals. 

The relations between the physical, chemical, and vital forces are strikingly 
exhibited in certain cold and warm-blooded animals, which become torpid or 
hybernate during the winter season. In this state all the chemical and physical 
actions are of the most sluggish character. The heart scarcely beats, the. frequency 
and force of the action of the heart and flow of the circulation is greatly diminished 
if not entirely stopped. The amount of carbonic acid thrown oflF from the lungs is 
greatly diminished, and all the chemical and physical changes of the elements of 
the tissues, and fluids, and organs of these animals are retarded. If the tempera- 
ture of a warm-blooded animal be reduced, in like manner all its physical, chemical, 
and vital actions will be depressed, and the active animal will be reduced to the 
condition of a sluggish cold-blooded animal, and death will rapidly ensue. There 
is, however, this great difference between the cold and warm-blooded animal — the 
conditions of the existence of the latter are far more restricted than those of the 
former. The chemical changes of the cold-blooded animal are slow, and it can 
exist without food for weeks and months, whilst a few days' starvation is fatal to 
the warm-blooded animal. These facts demonstrate conclusively that the condi- 
tions and phenomena of life are complicated and restricted, in exact accordance 
with the development and perfection of the organs and tissues of animals, and the 
rapidit}' of the chemical and physical changes of the molecules of their bodies. 



MALAEIAL FEVEE. 



49 



in the vegetable kingdom, by the combined actions of the vital 
principle, and the physical and chemical forces of matter and the 
sun ; perfect in its mechanical structure, and in the arrangement 
of its parts, with the size of its organs, the strength of its muscles 
and bones, and the vigor of its forces, constructed and arranged 
with exact reference to the force of gravity, the size of our globe, 
and its relations with the sun, and all other worlds in the uni- 
verse — worked by forces, always the resultants of the chemical 
changes of those substances which, in the vegetable kingdom, have 
been elevated into a state of force, by the action of the sun upon 
matter in the vegetable laboratory — worked by forces to which 
the great laws of mechanics apply — possessing intellectual facul- 
ties, capable of receiving impressions from the motions of exterior 
bodies, and of exciting the forces by which they are surrounded, and 
directing them so as to act upon exterior matter, and overcome all 
the barriers and obstacles of nature, not by a suspension or altera- 
tion of her laws, but by peculiar applications of those forces and 
laws — endowed with moral faculties which distinguish him from 
every other form of matter, and every other being upon our globe — 
revolving with the earth and planets around the sun, and with the 
whole system, moving through the great ocean of space, around a 
distant unknown centre — with an existence like that of plants 
and animals dependent upon the length of the day and of the year, 
and of the seasons, which are dependent upon the adjustments 
of the solar system ; dependent upon the constitution of terrestrial 
bodies, and their relations with celestial bodies. 
Man^ then, is a type of the universe. 

If a single one of the nice adjustments and relations of the com- 
ponent members of the solar system were materially altered, or 
even if the relations of the solar system with the exterior universe 
were materially altered, derangement of the structures, and final 
destruction of the human race must follow. 

To understand the phenomena of man in health and in disease, and 
his relations to the universp, we must comprehend the phenomena and 
mutual relations of all animate and inanimate bodies^ terrestrial and 
celestial. 



50 



OBSERVATIONS ON 



CHAPTEE II. 

THE EXTENT, OBJECTS, AND IMPERFECTIONS OF PATHOLOGICAL 
INVESTIGATIONS. 

In the preceding cliapter we endeavored to sketch the general 
relations of man to the exterior universe, and demonstrate the 
extent and complexity of his phenomena. 

If man be related to celestial and terrestrial bodies — if the ex- 
istence of man be dependent upon the adjustments of the solar 
system, the seasons, the climate, the action of the vegetable king- 
dom, the soil, and upon the great circulation of matter, kept up by 
the forces of the sun — if the derangement of only one link in this 
complicated chain of phenomena would result in the destruction of 
the human race — if the phenomena of man in health be thus com- 
plicated, how much more complicated must be the phenomena of 
disease, when the constitution of the complex solids and fluids of 
man may be altered in many ways, and the relations between the 
physical, chemical, vital, and nervous forces, and intellectual and 
moral faculties may be correspondingly deranged. 

In view of the immensity and complexity of physiological and 
pathological phenomena; in view of the fact, that no single man, 
even during a long lifetime, is capable of investigating thoroughly 
the phenomena presented by only one disease, the in\restigator 
should always state clearly his views of the extent and bearing of 
physiological and pathological phenomena, and define the scope 
and bounds, and methods of his investigations, and candidly ac- 
knowledge their omissions and imperfections. 

We will now proceed, in a condensed and brief manner, to point 
out the sources of disease. 

1. Astronomical changes are attended by corresponding changes 
in the phenomena of man. The changes of the day, and month, 
and year, and seasons are attended by corresponding changes in 
the constitution and phenomena of man. Not only would derange- 
ment of the adjustments of the solar system be attended by corre- 
sponding derangements in the little world of man, but his diseases, 



MALARIAL FEVER. 



51 



arising from whatever cause or causes, must be influenced by these 
changes. As the sun with his attendant planets are progressing con- 
tinuously through space, it is not unreasonable to suppose that the 
phenomena of man might be modified by the properties and forces 
of the regions of space through which the solar system travels. 
That a resisting medium does exist in space, to which the trans- 
mission of luminous and thermic vibrations may be referred, has 
been conclusively demonstrated by astronomers in the case of 
Encke's comet. What the matter is composing this resisting me- 
dium, and whether this matter is uniform, or varies with the dif- 
ferent regions of space, and whether it exerts any influence upon 
the phenomena of man, are questions worthy of a solution. 

Geology teaches that the climate of this earth has been altered 
during different periods of past times, and that causes have in past 
time's destroyed whole races of plants and animals. Whether these 
causes were astronomical or terrestrial, it is nevertheless true that 
similar causes may be the sources of disease. 

2. The surrounding medium may be physically and chemically 
altered, either by an excess or deficiency of its ordinary ingredi- 
ents, or by an excess or deficiency of the forces by which it is cir- 
culated. 

Whilst it is true that the amount of force annually received by the 
earth from the sun is a fixed quantity, it is nevertheless true that, 
owing to the peculiar constitution of the atmosphere, the nice adjust- 
ment of its forces (the ease with which one mode of force may be 
converted into another, as heat into electricity, and vice versa), its 
relations to moisture, its relation to the distribution of the forces of 
the sun, and its relations to the distribution of the solid and fluid 
masses of the earth; the climate is subject to variations which can- 
not be predicted, and are not uniform. Corresponding disturbances 
are produced in the phenomena of man. The truth of this propo- 
sition is conclusively demonstrated by the relations of certain dis- 
eases, as pleurisy and pneumonia, to the weather. And even when 
diseases are not directly produced by the disturbances of the struc- 
ture and forces of the surrounding medium, it is nevertheless true 
that the course and phenomena of disease are modified, to a great 
extent, by meteorological phenomena. The value of the determina- 
tion of these relations in the investigation of the origin, progress 
and treatment of disease, cannot be over-estimated. 

3. As the compounds composing the body of man have all been 
formed by the vegetable kingdom, from the inorganic elements, it 



52 



OBSERVATIONS ON 



follows that any deficiency of the necessary elements of the soil 
would be attended by deficiencies in the constitution and by com- 
position of the food, elaborated by the vegetable kingdom, and by 
corresponding disturbances of the constitution and phenomena of 
man. Corresponding changes in the constitution and phenomena 
of plants may be induced by meteorological phenomena. Hence, 
in the investigation of the origin and phenomena of disease, it. is 
necessary to determine the chemical and physical constitution of 
the soil, and its relations to the vegetable kingdom. 

4. The salts of the blood, which are absolutely necessary for its 
healthy constitution, are obtained in part from the water daily 
introduced into the system. These salts may exist in deficiency 
or excess; and other abnormal noxious, saline and organic matters 
may exist in the water. Each of these causes may be a source of 
disease. Hence the necessity in pathological investigations of a 
careful examination of the water. 

5. Any one of the normal constituents of the body of man may 
be deranged, and occupy different relations to each one of the other 
constituents. As these constituents are numerous, the resulting 
derangements may be correspondingly numerous. The forms of 
this class of diseases may be as numerous as the different positions 
which the elements may be made to assume towards each other. 

6. Any one of the elements of his body may be in, excess or de- 
ficiency, and the diseases may be as numerous as the elements 
themselves, and at the same time, totally different from the dis- 
eases arising from an alteration in the relative position of the ele- 
ments. 

7. Foreign morbific agents may be introduced into the fluids 
and solids, which will excite abnormal changes in the solids and 
fluids. The generation of these morbific agents will depend, in 
great measure, upon the relations of climate and soil, and water 
and organic matter, and the forces of the sun. The number of dis- 
eases of this class will correspond to the number of distinct mor- 
bific agents. 

Combinations of these morbific agents may produce still more 
numerous and complicated diseases. 

8. As the matter composing the human body is fashioned into 
definite organs and tissues destined to accomplish definite results, 
and combined into apparatuses, definitely related to each other, 
it is evident that the disturbance of the mutual relations of any one 
of these organs and tissues and apparatus must, to a greater or 



MALARIAL FEVER. 



53 



lesser extent, produce corresponding disturbances in the component 
members of the human organism. 

9. The Creator has associated the vital force with a definite con- 
stitution of matter. Whatever interferes with this constitution, 
interferes with the action of the vital force. Whatever interferes 
with the vital force, necessarily disturbs its relations with the phy- 
sical, chemical, and nervous forces. If the balance of the forces, 
their correlation be disturbed, the chemical actions between the 
elements may not only be deranged in kind, but also in degree, 
and the generation of the physical forces which work the machinery, 
and the manifestation of the nervous, intellectual and moral pheno- 
mena, correspondingly altered. 

10. The development and structure of the vegetable kingdom — 
the development and structure and actions of the most simply con- 
structed animals — the appearance of the nervous system in the 
animal kingdom, and in the foetus of the higher animals, subse- 
quently to the grouping of the atoms of formless matter into defi- 
nite forms and apparatuses — the formation of the digestive and 
circulatory apparatus, before the formation of nervous cells and 
nervous systems, demonstrate unequivocally, conclusively, and 
absolutely, that development, nutrition, and the direction of the 
forces of matter to the fashioning of another part are under the 
guidance of the vital principle — demonstrate unequivocally, con- 
clusively and absolutely, that the nervous system is itself developed 
and its perfection maintained under the guidance of the vital prin- 
ciple. Hence diseases may arise independently of the nervous 
system. Hence we may have chemical and physical changes of 
the elements of all the organs and systems of organs, incompatible 
with the existence of the vital force in that altered matter. 

Whilst we admit these propositions, we must at the same time 
bear in mind the true offices of the nervous system. The nervous 
system is the last and best work of the forces of matter directed by 
the vital force, and is destined to form the medium of communica- 
tion between the intellectual faculties and the exterior world ; and 
is destined to connect together and influence the various organs and 
apparatuses ; and is destined to regulate secretion and excretion, 
and the consequent development of force; and is destined to excite 
and control the actions of the dynamic muscular apparatus, not by 
the possession and emission of a peculiar force generated de novo, 
but rather by a modification of physical force generated by the 
mutual chemical reactions of the blood and nervous systems. 



54 



OBSEEVATIOXS 0:N" 



That the nervous force is not capable of itself of carrying on the 
acts of nutrition, secretion and excretion, is conclusively demon- 
strated by the fact that plants, and the simply constructed animals, 
which are devoid of a nervous system, are capable of carrying on 
the offices of generation, development, digestion, assimilation, nutri- 
tion, secretion, excretion, and of preserving a definite form amidst 
unceasing chemical changes. Many of the simply organized ani- 
mals, although without a nervous system, still possess sensation 
and voluntary motion. The nervous system appears only when the 
parts of the machinery are complicated, and need special means 
of communication. 

The development and perfection of the nervous system corre- 
spond exactly to the development, perfection and complication of 
the organs and apparatus. This fact is true of the animal kingdom, 
in its successive degrees of development, and also of the successive 
stages of the development of the solids and fluids of each individual 
highly organized animal. Physical and chemical actions take place 
in a similar manner in all animals, simple or complex ; they differ 
only in intensity. The higher the animal, the more complicated 
its parts, the more rapid the chemical changes, and consequent 
generation of the forces, and the greater is the necessity for some 
special apparatus which will bring all the complex organs and 
apparatus and actions into harmonious relation. 

Unless the actions of different organs can be telegraphed (so to 
speak) to each other, confusion in a complicated organism will 
necessarily result. Thus, if the amount of blood circulating through 
any organ and the chemical actions are too great, hov^^ can they be 
regulated without some medium of communication, and some means 
of regulating the chemical and physical actions. 

The observations and experiments of Eufus Ephesus/ Galen, ^ 
Piccolhomini,^ Eiolan,^ Plempius,^ Wills,^ Chirac, "Winslow, Bohn,^ 
Duverney, Yieussens,^ Schrader, Valsalva, Morgagni, Baglivi, Con- 

' Appellationes, Part. Hum. Coi-p. Greece. Parisiis, 1554, p. 32. 

2 Galeni Opera. Venetiis, apnd Juntas, 1576, do Hippocr. et Plat, decretus, lib. 
ii. cap. vi. p. 238. 

3 Anatomicje Praelectioues Arcliang. Piccolhomini, Romse, 1586. 
* Opera Auatomica. Lutetise Parisiorum, 1649. 

5 Fundamenta Medicinse. Lovanii, 1644. 

6 Opera Omnia, edente Balsio. 1682, torn. i. Nervorum Descriptio. 

7 Circulus Anatom. Physiol. Lipsise, 1697. 
^ Treatise on tlie Heart, Toulouse, 1715. 



MALARIAL FEVER. 



55 



ter, Berger,^ Ens Sinac, Huermann, Hallerj^ Brunn,^ Molinelli, 
Petit,^ Fontana/ Cruikshank, Haighton, Meyer, Bichat,^ Dupuy- 
tren, Dumas,' Bainville, Provincal,^ Yesalius, Columbus Eiolan,^ 
Bidloo,^° Muralto, Chirac, Courten, Drelincourt,^^ Martin,^^ Emmet, 
Portal, Prochaska,^^ Winslow,^"* Le Gallois,^^ Philip, Lobstein,'^ 
Eeid,^' Krimer, Arnemann, Longet,'^ Brodie,'^ Chossat,^° McCart- 
ney,^^ Nasse,^^ Bernard, Hall,^'' Brown-Sequard,^^ and others, have 
demonstrated that to the nervous system is delegated this property 
of regulating the action of the organs and apparatus, and thus 
regulating the amount of oxygen and blood supplied to the organs 
and tissues and apparatus. 

The blood supplying the nutritive elements of the tissues and 
organs, and the materials for the secretions and development of the 

' Physiologia Medica, Francofurti, 1737. 

2 Memoires sur les parties sensibles et irritables, torn. i. 

^ Commentarii de rebus in Scient. Nat. et Medic. Lipsiae, torn. iv. 

4 Memoires de I'Academie des Sciences, an. 1727. 

^ Traite sur le Venin de la Vipere. 

^ Rechercli. Plijs. sur la Vie et la Mort, Insere dans la Bibliotli. Medic, torn, 
xvii. p. 1. Physiological Researches on Life and Death, by Xavier Bichat, trans, 
by F. Gold, London. 

Journal General de Medecine, par M. Sedillot, torn, xxxiii. 

^ Bulletin des Sciences Medicales. 

p Encheididium Anatom. Parisiis, 1658. Opera Anatomi. 
'° Exercitationes Anatom. Chirurg. Lugd. Batav., 1708. 

Experimenta Anatom. Lugd. Batav., 1681. 
'2 Essais et Observ. de Medecine de la Societe d'Edimbourg. Paris, 1742. 

Opera Minora. Viennae, 1800, torn. ii. 

Exposition Anatom. Traits des Nerfs. 

Experiments on the Principle of Life, and Particularly on the Principle of the 
Motions of the Heart, and the Seat of this Principle, by M. Le Gallois. Translated 
by N. C. and J. G-. Nancrede, Philadelphia, 1813. 

^6 Structure, Functions and Diseases of the Human Sympathetic Nerve, by John 
Fred. Lobstein. Translated by Joseph Pancoast, M. D., Philad., 1831. 

" An Experimental Investigation into the Functions of the Eighth Pair of 
Nerves," by John Reid, M. D. Edinburgh Medical and Surgical Journal, 1838. 
Traite de Physiologie, Paris, 1850, t. ii. 
'9 Medico-Chirurg. Trans., 1837, vol. xx. p. 132. 

2° Mem. sur I'influence du syst. nerv. sur la chal. anim. These de Paris, No. 126, 
1820. 

2' Treatise on Inflammation, 1838, p. 13. 

22 Untersuchungen zur Physiol, und Pathol., 1839, vii. 

23 Gaz. Medic, de Paris, vol. vii. No. 14. 

2* Phil. Trans., 1833. On the Diseases and Derangements of the Nervous Sys- 
tem, by Marshall Hall, M. D,, London, 1841. 

25 Experimental Researches applied to Physiology and Pathology, by E. Brown- 
Sequard, New York, 1853. 



56 



OBSEEVATIONS ON 



forces, and oxygen being the active agent in all the chemical ac- 
tions of the bodies, it is evident that whatever disturbs the consti- 
tution of the nervous system, necessarily disturbs the functions of 
the apparatus and organs, and produces corresponding alterations 
in their secretions and excretions. 

As the integrity of the nervous system depends upon the in- 
tegrity of the blood, in like manner whatever alters the constitu- 
tion of that fluid will produce aberrated action in the nervous 
system, and in turn, this disturbance may extend itself indefinitely. 

Disease, then, whether arising in the organs, or in the blood, or 
originally in the nervous system, will always be attended by aber- 
rated nervous action. The most prominent symptoms of disease 
will be manifested by the nervous system. 

The value of the phenomena manifested by the nervous system 
during febrile diseases, has been recognized by no one more fully 
than Professor Henry F. Campbell,' M. D., in his able and elaborate 
classification of fever by the nervous phenomena. 

In all our investigations into the causes and effects of disease, we 
should always remember the distinction between the offices and 
phenomena of the two systems of nerves, the cerebro-spinal and 
sympathetic. 

Long before Haller, the intellectual functions, sensation, and 
voluntary motions, had been distinguished from those which are 
exercised without our knowledge, and over which our will has no 
command, such as circulation, nutrition, and secretion. The former 
were distinguished under the name of external animal functions, 
and the latter under the name of internal natural functions, and 
both orders of functions were known to be equally under the con- 
trol of the nervous power. Willis^ asserted the distinction between 
the nerves destined to voluntary motions and those which preside 
over the internal natural functions which are independent of the 
will. He placed the origin of the nerves of the external animal 
functions in the cerebrum, and that of the nerves of the internal 
natural functions in the cerebellum, and contended that if the 
motions of the heart as well as the other vital functions do not 

' Report on the Nervous System in Febrile Diseases, and the classification of 
Fevers by the Nervous System, by Henry Fraser Campbell, A. M., M. D., Professor 
of Anatomy in the Medical College of Georgia, at Augusta. Transactions of the 
American Medical Association, 1858. 

2 Tho. Willis opera omnia, edente Grer. Balsio. Amstelodami, 1682. Tom. i. de 
Cerebri Anatome, cap. xv. 



MALARIAL FEVER. 



57 



undergo any interruption, it is because the action of the cerebellum 
continues without ceasing; whilst on the contrary the voluntary 
motions require repose, because the action of the brain is inter- 
mittent. 

Boerhaave^ adopted the opinions of "Willis, and in the action of 
the heart, in addition to nervous action, he admits two other causes 
of its motions, and their harmony : the action of the blood of the 
coronary arteries upon the fibres of the heart, and of the venous 
blood in the internal surfaces of the cavities of the heart. Eecent 
experiments^ have rendered this opinion of Boerhaave more than 
probable. 

In 1752, Haller published his experiments upon irritability, 
which tended to establish the existence of an internal life inde- 
pendent of the nervous power, and demonstrated that the cause of 
animal motion resided in the muscular fibre itself. The opinion is 
now gaining ground with physiologists that the contraction of the 
muscles and all animal motions result from the chemical changes 
of the elements of the muscles and blood. Haller admitted that 
whilst the irritability of the muscles is the cause of all animal 
motions, it cannot produce them without a stimulus, and that the 
nervous power is the natural stimulus of all those which are sub- 
mitted to the will, whilst the involuntary muscles acknowledge 
stimuli of various sorts, which are appropriate to their functions, 
and wholly abstracted from the nervous power. According to 
Haller, the blood is the natural stimulus of the irritability of the 
heart; and alimentary substances the natural stimuli of the intes- 
tinal canal : and the motions of these organs are not submitted to 
the will because they are independent of the nervous power. This 
theory of Haller, although imperfect, and in some respects errone- 
ous, nevertheless expressed great truths which are now being de- 
monstrated. Careful experiments demonstrate that Haller v/as in 
error when he asserted the independence of the heart and the intes- 
tines of the nervous system ; and Prochaska,^ in 1784, admitted the 
nervous power as one of the conditions necessary to the manifesta- 
tion of irritability, and accounted for the fact that the motions of 
the heart were not stopped by the entire suppression of all com- 
munication between the brain and the heart, by the abandonment 

* Her. Boerlaaave Inst. Medicse, § 409. Vanswieten in Aphorismis, &c. Lugduni 
Batav., 1745. Tom. ii. 
2 Brown-Sequard. 

^ Commentatio de Functionibus Systematis Nervosi, 1784. 
5 



58 



OBSERVATIONS ON 



of the then generally received opinion that the brain was the centre 
and only source of the nervous power, and by the adoption of the 
opinion that the nervous power is produced in the whole extent of 
the nervous system, even in the smallest nerves, and that it can 
exist independently of the brain, for a certain time. 

"Willis^ and Vieussens^ acknowledged the general relations of 
the sympathetic system with the cerebro-spinal, and considered the 
sympathetic as the medium by which the sympathetic relation is 
rendered so remarkable between the cerebrum and the viscera of 
the middle and lower parts of the abdomen, and noticed the im- 
portant physiological and pathological facts that not only do the 
various conditions of the brain afiect the viscera, but the affections 
of the viscera affect the brain as well as the mind itself. 

The observations and researches of Winslow,^ Grirardi,'' Fontaria,"* 
Jacobson,^ Lobstein,^ Kibes,^ Killian,^ Laumonier,^ Cloquet, '° Scarpa, 
Hasse, and others, established the structure and distribution and 
communications of the sympathetic system of nerves, and laici 
the foundations for the philosophical generalizations of the physio- 
logical and pathological phenomena. 

Scarpa demonstrated by actual experiments, that the sympathetic 
system receives nerves from all parts of the nervous system, the 
brain and spinal marrow, and that all the viscera receive nerves 
composed of many separate filaments from different sources. 

Wiirtzel divided all the ganglia of the sympathetic system into 
three orders, the cerebral, spinal, and vegetative, and affirmed 
that they differed essentially from each other in their structure, and 
in their behavior under the action of chemical agents. 

Prochaska distinguished the nerves of motion from those of sen- 
sation, and affirmed that the heart cannot contract itself, unless the 
impression of the stimulus upon its cavities is transmitted to the 
ganglions of the system of vegetative life, through the nerves of 

' Nervorum Descriptio et Usus. Cap. xxvi. Opera Omnia. Grenevse, 1695, tome i. 

^ Neurograph. Univers., lib. 3 de Nervis, cap. v. 

^ Exposition Anatomique, Traite des Nerfs. 

^ Journal de Medecine, Chir. et Pliarm., par Bacher, torn, xciii. 

5 Acta regise Societatis Hafniensis Medicse, vol. v. Hafnise. 

6 Structure, Functions, and Diseases of tlie Sympathetic Nerve, hy J. F. Lob- 
stein. Trans, by J. Pancoast. Phila., 1831. 

Dictionnaire des Sciences Medicales, torn. Ivi. 
^ Anatomische Untersucbung uber das Neunte Hirnnervenpaar, Pesth, 1822. 
9 Journal de Medecine, Cbirurgie et Pliarmacie, par Bacber, torn, xciii. 
'° Traite d'Anatomie Descriptive, torn. ii. 



MALARIAL FEVER. 



59 



Sensation, and thence reflected to the fibres of the heart, through 
the nerves of motion. Whilst admitting the connection of the 
sympathetic system with the action of the heart, he is confused 
and uncertain in his account of the functions of the ganglions, 
which he appeared to consider as knots and ligatures, tight enough 
to intercept all communication in the calm and quiet state, but not 
sufficiently tight to prevent the action of the nervous force, gene- 
rated in the brain during the agitation of the passions. He asserted 
that it is through the nerves of the eighth pair that the effect of 
the passions is felt upon the heart. 

In common with Winslow, Wintrel, Johnstone, and others, Pro- 
chaska believed that the ganglia of the sympathetic system were 
so many little brains capable of supplying the necessary nervous 
force to the viscera. 

Bichat acknowledged an animal and organic life distinct from 
each other, and affirmed that the system of ganglions (sympathetic 
system) belonged entirely to the organic life, and that the cerebral 
system belonged entirely to the animal. 

Whilst Bichat understood the influence of the several parts of 
the nervous systems, he failed to recognize their mutual connec- 
tions. The mutual relations of these systems were established by 
the exact and philosophical experiments of Le Gallois.^ 

' In his work, whicli was pronounced by Humboldt, Halle, and Percy, the com- 
missioners of the French Institute to whom it was referred, " the most important 
physiological work that had been produced since the learned experiments of 
Haller — the most unexampled work in physiology, every part of which is so con- 
nected and so dependent upon each other, that to arrive at the perfect explana- 
tion of a fact, it is necessary to reascend to all those by which the author had 
arrived at it ; and that no one deduction can be denied, without denying all the 
preceding ones, or raising a doubt respecting those which follow." Le Grallois, by 
an extensive series of experiments, arrived at the following conclusions : — 

" Life is produced by an impression of the arterial blood made upon the brain 
and medulla spinalis, or by a principle resulting from this impression. 

" The prolongation of life depends upon the continual renewal of this impression. 
The property of the principle in question to survive wounds, and a very consider- 
able destruction of the rest of the body, provided its peculiar seat has not been 
injured, affords a ready criterion for determining in what part of the nervous ap- 
paratus the primum mobile of such a function resides. For whenever, by destroy- 
ing a certain portion either of the brain or of the spinal marrow, you cause the 
cessation of a function suddenly, and before the known period when it would cease 
naturally, you may be assured that this function depends upon the part that has 
been destroyed. It was in this manner that I discovered that the primum mobile 
of respiration had its seat in that part of the medulla oblongata which gives rise 
to the nerves of the eighth pair ; and it is by pursuing this mode, that one might, 



60 



OBSEEVATIONS OX 



The results of the experiments of Le Gallois were confirmed 
and extended by the minute, elaborated, and extensive anatomical, 

to a certain degree, discover the use of certain parts of tlie brain, so much the ob- 
ject of speculation, but hitherto only defined in systems produced by a lively 
imagination. . . 

" It is this impression, this principle formed in the brain and spinal marrow, 
which, under the name of nervous power, and through the medium of the nerves, 
animates all the rest of the body, and presides over all its functions. 

" The heart derives all its po\^ers from this principle, as do all the other parts, 
the sensation and motion with which they are endowed, with this difference, that 
the heart derives its power from every point of the spinal marrow, without excep- 
tion, whilst every part of the body is only animated by a portion of that medulla 
(by that which is supplied with nerves) ; a difference which may serve to explain 
the intensity of the power of the heart, and its uninterrupted continuance, from 
the moment of conception, till the hour of death. 

" From the great sympathetic nerve, the heart receives its principal nervous fila- 
ments ; and it is only through that nerve, that it can receive its energy from every 
point of the spinal marrow. The great sympathetic must, therefore, have its origin 
in this medulla ; and thence the numerous questions that have been raised on the 
origin of this nerve, namely, whether it proceeds from the brain or from the spinal 
marrow ; or, as Bichat pretends, whether those different portions are only branches 
communicating from the ganglions, which this author considers as so many smaller 
brains, forming a distinct nervous system, independent of the brain and the spinal 
marrow. All these questions, hitherto inexplicable in anatomy, are completely de- 
termined by experiments. . . 

"From the same principle, we can no longer admit the assertion of Bichat, 
though pretty generally adopted, that there is in the same individual two distinct 
lives, one animal, the other organic ; that the brain is the only centre of animal 
life ; and that the heart, independent of the brain and of the nervous power, is the 
centre of life. 

" It must, however, be observed, that there is a real and a very important dis- 
tinction to be made between the organs that receive their nerves from the great 
sympathetic, and those which receive theirs immediately from the medulla ob- 
longata and spinal marrow. 

" The former receive their principle of action from the whole nervous power ; 
their functions are not submitted to the will ; they are exercised in every instant 
of life, and, at most, suffer only remissions. 

" The latter, on the contrary, have their principle of action in a limited portion 
of the nervous power ; their functions are submitted to the will ; they are tempo- 
rary, and can only be repeated after complete intermissions of longer or shorter 
duration. 

" This distinction comprises nearly the same organs as that of the two lives ; but 
it is evident that it rests upon a basis entirely different, since the organs of organic 
life, which, in the system of the two lives, is considered as independent of the brain 
and of the spinal marrow, are precisely those which receive the most powerful in- 
fluence from it. 

"Numerous anatomical, physiological, and pathological facts can only be con- 
ceived and accounted for by this distinction. For instance, it is known that cer- 
tain pains in the bowels cause debility, prostration of strength, and great disorder 



MALAEIAL FEVER. 



61 



physiological, and pathological researches of Lobstein/ who antici- 
pated many of the results of recent experiments and research. 

throughout the animal economy. This fact, which is unaccountable in the system 
of the two lives, is readily understood, from the moment we reflect that the intes- 
tines derive their principle of action from all parts of the nervous power, through the 
great sympathetic, from which they receive their nerves ; and that consequently, 
their affections ought to react immediately upon every part of this same power." 

" Experiments on the Principle of Life, and particularly on the Principle of the 
Motions of the Heart, and of the Seat of the Principle," by M. Le Gallois, M. D. P. 
Translated by N. C. and J. G. Nancrede, M. D., Philadelphia, 1813, pp. 142-148. 

' The following quotations from the elaborate work of Lobstein upon the Struc- 
ture, Function, and Diseases of the Sympathetic Nerve embody the most important 
results and generalizations established by this author, and illustrate in a forcible 
manner the relations between the cerebro-spinal and sympathetic systems. The 
author sums up in the following manner the theories of Reil and others : — 

" The cerebral nervous system is formed differently from that of the sympathetic 
system. The branches of the former converge from the periphery of the body 
towards the cerebrum, and are inserted into it by their roots, as the roots of vege- 
tables are in the soil ; that system, therefore, has but one centre, which is in the 
encephalon. The latter, on the contrary, is not collected into any centre ; it has 
no focus of action, but exercises its functions over a wide surface. 

" The sympathetic system connects the organs together in three different modes. 

1. It forms networks around the vessels, which embrace the arteries with their 
slender and minute branchlets (as the ivy clasps the stem of a tree), and pene- 
trates with them to the organs. These networks are known under the name of 
plexuses, twelve of which are enumerated, appertaining to different parts. * * * 

2. These plexuses are connected to the brain and medulla spinalis by branches 
which Reil calls conductors. ^ * * 3. These branches, the conductors of the 
plexuses, appear to form a perfect connection between the animal and vegetable 
systems ; every commotion which the lower viscera suffer would be conveyed to 
the sensorium commune, and vice versa — the will would exercise a perfect control 
over the organs of the thorax and abdomen, were not these movements intercepted 
by enlargements in the conductors called ganglia." — pp. 72, 73. 

" When the two nervous systems by which the animal is rendered more perfect 
are considered physiologically, each may be esteemed a sphere of activity in 
which the vital actions are differently performed. In the animal sphere (that is, 
in the cerebrum, the medulla spinalis, and their nerves) the determination of the 
will and senses, when transferred to the common sensorium, become impressions 
instanter, and, as it were, at a single impulse. In the vegetative sphere the nerv- 
ous energy is slowly, steadily, but obscurely, dispersed into the organs. These are 
connected together, act according to their peculiar laws, and compose a system 
separate from the animal sphere, over which appropriate laws preside. This sys- 
tem also possesses the faculty of perception — namely, it receives impressions, and 
reacts upon them ; but this perception abides in its own region, and is not commu- 
nicated to the brain. In a healthy state, the system of ganglia exerts no manifold 
influence upon the cerebral system, from which it is divided by the separatory or 
isolating apparatus, the series of ganglia in the sympathetic nerve. But the case 
is different in a state of disease, for when the vital energy is increased in the com- 
municating nerves of the plexuses, the condition of the ganglia is changed ; they 



62 



OBSEEVATIOXS OK" 



transmit impressions whicli the extremities of tlie nerves in the viscera receive, 
and become conductors, whilst before they were non-conductors or isolators." * * 
—pp. 74, 75. 

" In the foetus none but the sympathetic nerve is in vigorous action ; it exists 
previous to the secretory and nutrient organs ; it sustains the energy of the heart ; 
and breaks in sometimes upon the cerebral sphere, and determines those automatic 
motions which the infant, when closed in the uterus, performs with its muscles. 
Acephalous foetuses, destitute of cerebral and spinal medulla, and hence wanting 
the nervous centre from which emanates the principle of muscular contractions, 
perform, nevertheless, muscular movements which can be in no other way excited 
than by the vital influence of the sympathetic nerve, which is joined by an anas- 
tomosis with the spinal nerves." — p. 77. 

" During the extra-uterine life of man, when there exists some immediate internal 
sense inherent to the stomach, this nerve forms a remarkable intercourse between 
the cerebrum and the viscera of the thorax and abdomen, as is proved by number- 
less phenomena. Then, as in the embryo and foetus, it governs the system of 
capillary vessels, and directs the functions of assimilation and nutrition, through 
the influence of the vital plastic power, which Broussais calls vital chemistry." * * 
-p. 77. 

After this general statement of the theories broached and facts established by 
others, Lobstein proceeds to give the results of his own investigations. 

" No one will certainly deny that there exists in animals a certain central influ- 
ence with which the duration of life is intimately connected. No one will deny 
that this central influence is inherent, not to the osseous, vascular, or muscular 
systems, or nutrient organs, but to that initial system which is nobler than the 
rest, and involves the first character of animality, and after removal of which all 
power perishes — viz., the nervous system." — p. 77. 

After a careful examination of the origin and development of the nervous sys- 
tem in the animal kingdom, he concludes— 

*' 1. That there is a nervous system in the invertebrate animals which is marked 
with ganglia. 2. That in the lowest order of these animals the first nervous mass 
found belongs to a nutrient organ. 3. That other tubercles are speedily added in 
animals a little superior in the scale, which are not dissimilar to the cerebral 
system. 

" In animals of a superior order the motorial and sensorial ganglia of the organs 
are inflated, as it were, into one system, the cerebral, in which the gangliform 
figure disappears ; so, on the other hand, the organs employed in nutrition are 
formed into a peculiar system in which the primitive arrangement and form of the 
nerves remain, and which (as in the lowest class of animals) closely surround the 
intestinal canal with their branches. 

"According to a corollary of the greatest importance, there exists a relation 
between the sympathetic nerve and the par vagum — to wit, that one may take 
upon it the functions of the other ; for in the inferior vertebrated animals the par 
vagum appears to be more prolific in branches distributed to the intestines, as the 
sympathetic nerve is less ; and it is found that in some vertebrated animals no 
sympathetic nerve exists at all, and in which its functions are performed by the 
par vagum only. Whence it follows that the par vagum should be classed under 
the same law as the sympathetic itself, with the nerves of vegetative life. In fine, 
in all orders of animals the sympathetic nerve is always found, in regard to its 
development, to correspond with the pre-existing vascular apparatus ; which proves 
that it owes its delicate construction to the wants of the vessels. 



MALARIAL FEVER. 



63 



" A nervous system wliicli exists in the lowest scale of animals is peculiar to tlie 
nutrient organs, and performs especial functions of its own, which, prior to the 
appearance of the brain, constituted a nervous centre, and which, when the cere- 
bral centre is formed in animals, is inter-connected only, and never composes with 
it one undivided apparatus, but always retains its pristine form and habit — that 
such a system is endowed with the greatest functional importance is self-evident." 
-^p. 81. 

" As to the forces, the branches of the sympathetic nerve are undoubtedly en- 
dowed with the same power as nerves in general ; that is, from the vital principle 
by which tone, strength, and energy are maintained in the organs over which they 
preside. It does not seem improba,ble that the ganglia which diversify the trunk 
ought to be considered as the laboratories of that principle, which the internal or 
egredient branches conduct to the viscera, and of the nature of which we are 
entirely unacquainted. In the cerebral voluntary nerves, as well as in the sym- 
pathetic nerve, the nervous principle traverses in both directions ; to wit, from the 
trunk into the branches, and again from the branches into the trunk." — p. 82. 

" But the branches of the sympathetic belong principally to the arteries which 
they envelop, while the finest filaments which follow the arterial branches into the 
organs are terminated in the external coat. Hence it is manifest that the vessels 
are primitively constituted under the government of the nerves, and that from 
them the force and energy are borrowed with which they operate in the functions 
of nutrition and secretion." — p. 83. 

" From all that has been hitherto produced, we are at liberty to conclude that 
there is no essential difference between the sympathetic nerve and the encephalic 
mass and spinal nerves, but that the two nervous systems are so far distinct that 
both are peculiarly situated according to the different conditions in which they 
exist in the body. 

In the anatomical part of this treatise it was first demonstrated that the trunk, 
branches, and filaments of the sympathetic nerve have the same structure as the 
cerebral and spinal nerves, the same plexiform division, and, when examined with 
the microscope, the same composition ; to wit, medulla and neurilemma. On the 
other hand, I know, from attentive observation, that the sympathetic nerve trans- 
mits the impressions it receives to the common sensorium in the same manner as 
the cerebral and spinal nerves. Thus an irritant afflicting the primae vise is per- 
ceived immediately by the brain, as the following demonstrates : 1. The tormina 
occurring in various diseases. 2. A calculus lodging in the biliary ducts, the 
pelvis of the kidneys, or the ureters. 3. An irritant near the hepatic plexus, from 
which an animal was seen to suffer by Haller. 4. The galvanic agent producing 
intense peristaltic motion, and secretion of the intestinal fluid, according to the 
experiments of Grapengeiser." — p. 87. 

"The sympathetic nerve presides over the function of nutrition, not only be- 
cause it imparts many nerves to the chylopoietic organs, and sustains their energy 
and influence, but because it is also distributed to the arteries, which carry the 
nutrient blood. 

" Let us suppose the nervous power destroyed in the abdominal plexuses ; the 
tone of the stomach, gastric, and intestinal digestion, and the functions of the liver 
and spleen would be impaired. 

" That this indeed may take place, is taught by numberless instances of mental 
disease, which, when thrown upon the solar plexus, suddenly disturbs the whole 
function of digestion. 

" The abnormal action of the abdominal nerves exercises an influence over the 



64: 



OBSERYATIOXS ON 



organs, in regions very distant from eacli oilier, from wliich it is manifest tliat the 
functions of assimilation and nutrition are under its subjection. Recently one of 
my intimate friends, vrho is about thirty years of age, after being suddenly terri- 
fied by the burning of bis bouse, bad bis bair to turn vrbite in tbe course of a few 
days. Was it not tbe mental suffering be experienced, wbicb, by tbe unanimous 
consent of pbysiologists, deranges tbe abdominal nerves, tbat in this case produced 
tbe change by disordering tbe force and functions of these nerves ? and did not 
this disordered action affect the nutrition of the capillaries ? 

" Pbysiologists have long since ackno-^ledged tbe great influence of tbe nerves 
over the capillary and nutrient vessels. Thus, if it is enhanced, tbe action of tbe 
latter is increased ; if diminished, weakened ; if utterly deficient, destroyed ; hence 
it is as they are maintained to supply this office, that they have not any control 
beyond it. Is it not then evident, that when tbe nerves are injured, nutrition 
■would be frequently destroyed? The experiments of Dupuy upon horses, in which 
the superior cervical ganglia were cut away from either side, furnish good proof of 
this ; contraction of the pupil, redness of tbe conjunctiva (phenomena since ob- 
served by F. Petit), emaciation of the whole body, oedema of tbe feet, and an uni- 
versal cutaneous inflammation followed the operation." — pp. 89, 90. 

" What I have said of nutrition in general, holds good in the secretions of the 
fluids, because the same mechanism supports secretion." — p. 91. 

" As we are considering pohysiological and pathological phenomena, we will ask 
if there be any ignorant tbat the secretion of the fluids in the glands may be in- 
creased by the effects of tbe imagination alone. 

" Who can deny that the maternal milk, the bland and sweet nutriment of in- 
fants, has been suddenly changed by mental affections to an atrocious poison ? 
No other instruments certainly exist but the nerves, by whose aid the psycholo- 
gical irritant can act upon the organs. 

" The sympathetic nerve governs the action of tbe heart and the circulation of 
the blood. 

"Tbe cardiac nerves have the same relation to tbe fibres of the heart, as the 
cerebral and spinal nerves with the voluntary muscles." — pp. 92-93. 

" The sympathetic nerve forms an admirable chain of connection between the 
principal organs of the human body." This proved anatomically and psychologi- 
cally and pathologically. "The sympathetic action is by no means circumscribed 
to the cavity of tbe abdomen ; on the contrary, it spreads itself wider, and con- 
nects the separate parts of the body in close union with itself. 

''Most of the phenomena, indeed, may be considered as consensual, in ivhich the si/ m- 
pathii is proved to arise from the connection and interlacing of the nerves. 1st. TitiJ- 
lation of the nose produces sneezing, because the nasal nerves of the spheno-palatine 
ganglion arc connected through the medium of the deep-seated and superfcial vidian 
nerves, icith the sympathetic ; from which the diaphragmatic plexus arises, ichich is 
joined by anastomosis of the phrenic nerve. 2d. An intense light also excites sneezing, 
for the impression being perceived by the retina, and transferred instantly to the ciliary 
nerves, is conveyed to the sympathetic, and by the nasal branch, and the remaining nasal 
nerves oftheffth pair. Sd. The anastomosis of this nerve (sympathetic) with the fifth 
pair, accounts for the gritting of the teeth, and itching of the nose, in the verminose 
diseases of children ; renal calculi, or nephritis, produce vomiting, or other disorders 
of the stomach, whilst the stimulating cause, if confined to the bladder, rarely excites 
gastric derangement. For the nervous communications are more conspicuous and 
more numerous between the kidneys and stomach, than between the stomach and 
urinary bladder. 5. The observations of celebrated practitioners instruct us, that 



MALAKIAL FEVER. 



65 



many laboring under diseases of the abdominal viscera, suffer cloudiness of vision, 
tbat tlie retina is also drawn into consent." — pp. 96, 97. 

" the medium through which the connection of the nerves is chiefly made, is the 
par vagum., the principal anastomoses of which with the intercostal nerve, in the neck, 
thorax, and abdomen, form many plexuses, upon which the action of the sympathetic nerve 
depends, and through the medium of which, chiefly, that admirable intercourse exists he- 
ticeen the head and abdomen, known to physicians in all ages.^^ — p. 97. 

" In tliis respect tbe fascia communicans of Wrisberg is of great importance, and 
wliicb, in my judgment, migbt be more aptly named, the great abdomino-cephalic 
anastomotic branch, for by it the animal life is connected with the nutrient or 
vegetative, so that the mutations of one may be immediately felt within the do- 
mains of the other, perceived by the mind, and vice versa. I shall allege some 
cases of abdominal disease in the third section of this work, in which this sym- 
pathy is sufficiently manifest in the morbid state." — p. 98. 

" The route by which the descending or ascending impression goes and returns, 
is none other than the abdominal fascia, or the abdomino-cephalic anastomotic 
branch. This alone, and uninterrupted by ganglia, forms the immediate inter- 
course between the cerebrum and abdomen." — p. 99. 

" In reflecting upon the nature of intermittent fevers, I have thought that it 
might, perhaps, be found in the disorder and perverted action of the abdominal 
nervous system, and there appear, indeed, to be sufficient grounds to render this 
opinion probable." * * * — p. 121. 

" The paroxysms of intermittent fever are tied down to a regular rhythmus, in 
consequence of their being radicated in the nervous system, upon which nature has 
impressed a law, according to which they must perform their functions periodi- 
cally."— pp. 121, 122. 

"Each nervous system, therefore, is obnoxious to its own diseases. But the 
mode in which the cerebral and spinal nerves, and the nerves of the abdominal 
plexuses and ganglia are affected by disease, is the same. As in the various kinds 
of convulsions, epilepsy, tetanus, etc., there is disorder in the voluntary nerves, 
even when no organic lesion can be discovered in them ; so the nerves of the tho- 
racic and abdominal viscera may be affected without any alteration perceptible to 
the senses. As the perverted action of the cephalic brain is reflected with great 
force upon the abdominal brain, so in turn does the latter react upon and over- 
whelm the former ; and finally as the cerebral system, when it is stupefied, as it 
were, by the violence of disease, destroys life, in like manner, I believe, an analo- 
gous effect takes place in certain diseases in the solar plexus." — p. 122. Connection 
of the sympathetic and cerebro-spinal systems, illustrated by numerous patholo- 
gical conditions. Effect of blow upon epigastrium, p. 122. Effects of the recession 
of miliary exanthemata in producing abdominal paralysis or apoplexy, hemicrania 
excited by hypochondria and hysteria, p. 122. Relations of affections of the head 
to the state of the ganglionic system and the bowels, pp. 124, 125. Explanation of 
delirium and of the action of cathartics in modifying the phenomena of fever, pp. 
122, 125-6. " Sympathy between the teeth and abdominal nerves," p. 127. 

" The perverted action of the brain is by no means circumscribed to the cavity of the 
cranium; it is extended to distant regions of the body, whence organic diseases are pro- 
duced. 

After lesions of the brain there is undoubtedlg a dynamic disorder of the nervous 
apparatus of the liver, antecedent to the inflammation and suppuration of that organ. 
Various hypotheses have been invented to explain the connection between the brain and 
hepatic system, none of which have yet been at all satisfactory. I may ivith better rea- 



66 



OBSERVATIONS ON 



The physiological and pathological relations of the sympathetic 
and cerebro-spinal nervous systems have also been subjects of 
elaborate investigation, by Dr. Samuel Jackson,^ Professor of the 
Institutes of Medicine in the University of Pennsylvania. 

son, refer it to a communication of the right par vagum with the solar plexus, by which 
the cerebrum is connected to the right semilunar ganglion, from whence emanate directly 
the posterior nerves.'''' — pp. 131, 132. 

Lobstein illusti*ated the relations of the sympathetic and cerebral system of 
nerves, and also the connection of the nervous system with diseases, by numerous 
pathological facts. The notes added by Dr. Joseph Pancoast also contain interest- 
ing corroborative facts. 

"A Treatise on the Structure, Functions, and Diseases of the Human Sympa- 
thetic Nerve," by John Fred. Lobstein. Translated from the Latin, with notes, by 
Joseph Pancoast, M. D., Philadelphia, 1831. 

1 The following quotations from his work on the Principles of Medicine, pub- 
lished more than a quarter of a century ago, will show that his views are profound 
expressions of those relations of the nervous system which are just now being 
recognized by the profession : — 

" Considerations, based on the anatomical structure, lead to the following infer- 
ences as to the functions of the ganglionic system : — 

a. " It is not independent of the cerebro-spinal nervous system, but derives its 
nervous activity from its connection with that system. 

b. '-It is connected throughout its whole extent by the numerous nervous fila- 
ments passing from one ganglion to another, and uniting together the diflferent 
plexuses. 

c. " The organs of the head, neck, thorax, and abdomen, with the genital organs, 
which receive nervous filaments from this system, are placed in a communion of 
actions and impressions, which are transmitted from one to the other, and it is 
thus the principal instrument of the sympathies between those organs. 

d. " Supplying the thoracic and abdominal viscera and genital organs with 
nerves, and communicating with the cerebro-spinal nervous system, it is the me- 
dium of communication between these organs and the nervous system of relation. 

e. " Supplying the abdominal and thoracic viscera and genital organs with 
numerous nerves, this system must be the chief agent in maintaining the exercise 
of their functions. 

/. " From the quantity of nerves which it distributes to the arteries, the close- 
ness with which these vessels are invested with those nervous filaments, and which 
are lost in their coats, it must exercise an active agency over their circulation, and 
in this manner influence the secretions and nutrition. 

g. " The muscles that receive nervous filaments from this system have this 
peculiarity, that they act without volition, or even consciousness. They must, 
consequently, receive the nervous stimulation for this purpose from the ganglionic 
system." — p. 37. 

" From physiological and pathological facts we derive a confirmation of these 
principles, and obtain additional light in arriving at a knowledge of the functions 
of this system." * * p. 37. 

" The ganglionic system furnishing the principal nervous supply to the surfaces, 
where are seated the instinctive wants of the organism, we have in the above facts : 



MALARIAL FEVER. 



67 



1st, tliat tlie ganglionic system is the nervous apparatus of tlie instincts and inter- 
nal senses ; 2d, that it communicates to tlie nervous system of animal life or rela- 
tion tlie w^rits of the economy ; and 3d, is capable of compelling that system to 
command the acts necessary to supply these wants. 

The interrogation of pathological phenomena will furnish additional elucida- 
tion to this subject. 

" Irritations excited in the mucous tissue of the stomach and small intestines by 
the impressions of irritating agents, will excite irritations in the brain, and some- 
times spinal marrow. 

" The acute inflammations of the gastro-intestinal mucous tissue rarely, it may be 
asserted never, fail to occasion cerebral or spinal inflammation. Hence, they are 
invariably attended with headache and delirium, pains in the back, and often 
neuralgic pains in the extremities ; they frequently occasion coma, apoplexy, hy- 
drocephalus, convulsions, and paralysis. The chronic inflammations of the same 
tissue are also productive of chronic inflammations of the cerebral organs, and 
hence we find mania, monomania, catalepsy, and hysteria, are frequently connected 
with that state of the digestive organs. The connection between the cerebro-spinal 
organs and the mucous tissue of the stomach and small intestines, by which the 
actions of the one are transmitted to the other, is most probably efl"ected through 
the nerves of the ganglionic system, and the inosculation of the solar plexus with 
the par vagum." * * * — p. 40. 

"None of the viscera that are placed under the influence of the ganglionic system 
of nerves, exercise so decisive and prominent an action over the cerebro-spinal 
nervous organs as the stomach and small intestines, especially the stomach. 

" With less promptness and less constancy the other organs in this connection 
respond to the morbid irritation of the gastric mucous surface. An example is 
afi"orded in acute gastritis, in which the eye is always injected with blood, the 
fauces and tongue are arid and inflamed, the lungs often partake of the disorder, 
and respiration is impaired or deranged. The liver, the kidneys, the genital 
organs, all display more or less of disturbance in their functions, corresponding to 
the degree of the gastric disease. The acute irritation of these organs are attended, 
in a like mode, with disorder and disturbance of the stomach and its functions. 
Thus, inflammation of the kidneys, uterus, liver, and sometimes of the eye, is 
productive of an irritable state of the stomach, exciting nausea and vomiting. 

" The above pathological phenomena exhibit : first, a close connection between 
the stomach and the brain, by which they mutually reflect their irritations on each 
other ; and second, that the difi'erent organs to which the ganglionic system sends 
nerves possess a free communion in their actions, which is most extensire and 
active between those organs most abundantly supplied with nerves. 

" The ganglionic system, from these facts, would appear to be the medium of the 
sympathies that bind together the viscera of the splanchnic cavities — the cranium, 
thorax, abdomen, and the genital organs." * * * — pp. 40-42. 

" While it cannot be doubted that the organs of the moral faculties and passions 
are situated in the brain, neither can it be denied that the viscera are not entirely 
passive in their exercise. 

" What is the exact part they perform, it is not easy to divine ; but every one is 
conscious of sensations of a peculiar kind, having either a pleasurable or painful 
character, experienced in the epigastrium, in the chest, and sometimes in other 
parts, while under the influence of moral emotions of an agreeable or distressing 
nature. 

" The participation of difi'erent organs of the thoracic and abdominal viscera in 



68 



OBSEEYATIONS ON 



tlie actions wliicli constitute the passions, is evidenced in tlie secretion of tears, or 
weeping in sorrow ; sobbing in grief ; the tremulous voice, or its total loss, with 
tremors of the muscular system in fear ; laughter in joy ; gaping in ennui ; the 
injected eye ; hurried breathing and quickened action of the heart in violent anger 
and rage, when uncombined with apprehensions ; and in the gastric stricture expe- 
rienced in the preceding painful emotions, as also in hatred, jealousy, &c., with 
often the copious secretion of bile. 

" These eflfects most distinctly indicate the extension of the cerebral actions, 
roused by the passions or affective faculties to the physical organs of the economy. 

" These organs, on the other hand, are observed to hold a decided power over 
the exercise of the passions, and to control their elicitation. 

" A state of inflammatory excitement or irritation in those organs opposes the 
gentle visceral excitement of the pleasurable passions, and they can be no longer 
experienced. When the stomach and thoracic organs are inflamed, it is not' pos- 
sible, even in those whose natural disposition inclines them to gayety, to excite 
feelings of that character or to provoke laughter. Joy, hope, and all the animating 
moral impressions, are dissipated, and the mind is plunged into gloom, depression, 
and despair. The chronic irritation of the digestive viscera is the most common 
cause of melancholy and hypochondriasis. Irritations of the digestive apparatus 
are often directed on the cerebral organs, and, by exciting irritation in them, carry 
a positive influence into the development of the passions. Thus irritations in the 
stomach metamorphose frequently the temper and character ; the gentle and mild 
become peevish and irritable, the gay morose, the fearful bold, the coward courage- 
ous, the merciful cruel. The irritations occasioned by ardent spirits in the stomach 
and brain give rise to the frequent quarrels and disputes about trifles when this 
pernicious habit is indulged, and the man who when sober is an affectionate hus- 
band, a tender parent, a faithful friend, when under the influence of intoxication 
is converted into a savage, unfeeling brute ; he is borne away by the most terrible 
and furious emotions ; he is no longer master of his actions, and is scarcely con- 
scious of the excesses he perpetrates." * * ^ — pp. 193, 194. 

" Sympathy is the medium connecting the organic actions of the different organs, 
and consists in the transmission to a remote organ, and the repetition in that organ, 
of the same mode of action which had been previously excited in some other organ. 
One organ is in this manner an exciter or stimulant to the actions of other organs, 
and concurs by this means to the maintenance of the vital activity of the whole 
organism. * * * 

"The improvement of physiological knowledge, by determining in a more precise 
manner the offices of the different tissues and organs, renders it certain that the 
nervous apparatus alone is capable of producing the phenomena to which the term 
sympathy is applicable." * * * — p. 590. 

" In the senses we have the positive demonstration of the transmission of im- 
pression from one organ to another distant organ. * A reciprocity and 
identity of action, it is apparent, prevails between the organs of the senses on the 
external surface, the recipients of external impressions, and the internal cerebral 
organs ; an action excited in the one being transmitted to and repeated in the 
other. -J^- * * In this example of the senses we have presented a series of phe- 
nomena corresponding exactly with those constituting the sympathies — an action 
excited in one organ transmitted to and reiterated in another. 

" Illustrations of a yet stronger character are furnished by the phenomena of the 
nervous apparatus, exemplifying in a more vivid light the character and mode of 
production of the sympathies. 



MALAEIAL FEVEK. 



69 



" A rneutal impression, an idea, the excitation of a moral emotion, excites or 
modifies tlie movements of the capillary circulation, or disturbs the regular func- 
tion of some important organ. The deep suffusion of the mantling blood in the 
face of the modest female, the eloquent language of the unuttered thought, is a 
striking exemplification of the influence of cerebral excitement over the capillary 
circulation. The effects of the passions on the heart, so frequently disturbed in 
its mode of action by moral emotions ; the disorders of the biliary secretion, and 
derangement of the digestive action of the stomach, induced by profound mental 
operations, are strong evidences of the transport of impressions by the nervous 
system. A still more impressive example is found in the erotic ideas in dreams, 
so stimulating the genital organs as to provoke in them the actual sensations of 
the venereal act, and the ejaculation of the seminal liquor. 

" In these examples is manifested an excitement transmitted by nervous com- 
munication from one organ, in which it is developed, to another organ, to which it 
is transported, and to which it is imparted." * ^ * — p. 592. 

" The power of transmission is common to all the nervous apparatus, and is the 
means connecting its diflerent portions. But for the transmission of the excitement 
of the organic actions a specific nervous apparatus is provided ; it is the ganglionic 
system, or the sympathetic — the nervous system of the viscera and organic life. 
By the arrangement and distribution of this system a nervous apparatus is pro- 
vided, independent of, yet most intimately connected with, the cerebro-spinal 
nervous system. It is endowed with the same force, nervous activity, fluid, or 
whatever name it may be known by. It possesses an analogous mechanism ; 
nervous organs or centres (the ganglia), nervous cords of communication or of 
transmission, and receptive expansions in the viscera. Its actions and influences 
are in a similar mode — impressions received, excitement of nervous activity, and 
transmission of excitement ; and it exercises a controlling and governing influence 
over all the splanchnic viscera, to which it is distributed, similar to that excited 
by the cerebro-spinal apparatus over the organs of locomotion, expression, sensa- 
tion, the intellectual and moral faculties." * * *— PP- 592, 593. 

" The two important centres which have been indicated as existing in the nerv- 
ous system are immediately connected to each other, and by this connection the 
two apparatuses are placed in communication, and direct relations established 
between them. This communication is established by the eighth pair, par vagum, 
or pneumogastric. Arising from the medulla oblongata, it sends branches to the 
ganglia of the neck and thorax, but is principally expended in anastomoses with 
the solar plexus and semilunar ganglia ; so that it may be either described as 
proceeding from these ganglia and terminating in the medulla oblongata, or, arising 
from this last, it terminates in the ganglia. 

" The communication formed by the par vagum or pneumogastric between the 
centres — the medulla oblongata and semilunar ganglia— establishes the intimate re- 
lation and immediate connection uniting the two apparatuses of the nervous organs 
— the cerebro-spinal and ganglionic or organic. By this connection impressions 
are mutually reflected from the one apparatus into the other ; and consequently 
the impressions of the viscera, especially those of the abdomen, which have no 
direct communication with the brain, reach that organ, while those viscera expe- 
rience themselves modifications from the influence of cerebral excitement." * * ^ 
—pp. 594, 595. 

" In the natural state of the organism the correlation and mutual play of the 
organs on each other, through the medium of the nervous system, and by the 
radiation of its ingenerated nervous activity, are not characterized by features so 



70 



OBSERVATIONS ON 



The experiments of M. Claude Bernard/ E. Brown-Sdquard,^ 
and others, and the researches of Henry F. CampbelP, Marshall 

striking as to be readily seized on and established. Tbej nevertheless do exist, 
and are what is to be understood properly of the synergia of writers. In the 
pathological state the evidences of this mode of connection and influence are too 
apparent to be misunderstood. The pathological phenomena are, however, no 
more than an exaggeration of the physiological phenomena. When an organ, iu 
a state of active irritation or acute inflammation, acts on another and distant 
organ, afi"ects it in the same manner, communicates its own condition, it is not that 
a connection is established which did not before prevail, or a mode of action and 
influence is brought into play which previously had no existence. The connection 
was already there ; the action and influence already had being ; and as from this 
natural or physiological connection and influence the organs harmonize and corre- 
spond to each other in health, so from the same cause are they participants of the 
same condition in disease. It is from this natural, fixed connection and influence 
that an organ pathologically excited, generating in itself, by the nervous elements 
of its structure, an excess of nervous activity, becomes a morbid or pathological 
excitant to the other organs embraced in the range of its nervous circle, or with 
which it is in most intimate nervous connection." * * * — pp. 599, 600. 

After making extensive application of these physiological principles to the treat- 
ment of disease, Dr. Samuel Jackson institutes a profound analysis of the pheno- 
mena of fever, and closes his work in the following words, which reveal his high 
appreciation of the value of the knowledge of the relations of the nervous systems 
and organs : — 

" The study of the connections of the organs, functional and sympathetic, is the 
complement of all physiological researches and the fulfilment of pathological in- 
vestigations. The more profoundly they are examined, and the more clearly they 
are understood, with the greater facility will the production of morbid phenomena 
be comprehended, the mysteries that involve the pathological state be penetrated, 
and the perplexities proceeding from the complications and diversities of disease 
be unravelled. Let them never be forgotten by the practitioner when he stands 
by the bedside of the sick. This knowledge is the rock on which he must build, 
would he erect a system of treatment at once rational, safe, and efficient."* — p. 619. 

' Lemons de Physiologie Experimentale Appliquee a la Medecine. Par M. Claude 
Bernard. Paris. 

2 Experimental Researches applied to Physiology and Pathology. By E. Brown- 
Sequard. New York, 1853. 

Experimental and Clinical Researches on the Physiology and Pathology of the 
Spinal Cord. Richmond, 1855. 

^ An Essay on the Influence of Dentition in producing Disease. By Henry F. 
Campbell, M. D., Demonstrator of Anatomy in the Medical College of Georgia. 
Southern Medical and Surgical Journal (new series), vol. vi., June, 1850, p. 321. 

Transactions of the American Medical Association, vol. vi. 

An Inquiry into the Nature of Typhoidal Fevers. Transactions of the American 
Medical Association, 1853. 

Excito-Secretory System of Nerves. Transactions of the American Medical Asso- 

* The Principles of Medicine, founded on the Structure and Functions of the Organism. By Samuel 
Jackson, M. D., Assistant to the Professor of the Institutes of Medicine and Clinical Medicine in the 
University of Pennsylvania, &c. &c. Philadelphia, 1S32. 



MALAEIAL FEVER. 



71 



Hall,^ and others, have still further extended the knowledge of the 
mutual relations of the sympathetic and cerebro-spinal nervous 
systems. But, after all that has been achieved by a host of devoted 
laborers, we have but the mere outlines of this vast subject, and 
our knowledge relates almost entirely to the most general and 
superficial phenomena. 

The true relations of the nervous system to disease must be 
based not only upon the relations of the sympathetic system to the 
organs, and to circulation, respiration, secretion, excretion, and nu- 
trition ; and of the cerebro-spinal system to motion and sensation ; 
and of the sympathetic system to the cerebro-spinal system ; but 
also upon the relations of the intellectual faculties to the nervous 
system, and through the nervous system to circulation, respiration, 
secretion, nutrition, and excretion. If the views promulgated by 
Prochaska and Gall be true, that each faculty of the intellect is 
connected with a special portion of the brain as the organic, mate- 
rial condition of the associated faculty, then aberration of those 
faculties would point to organic or functional alterations of the 
corresponding portions of the brain, just as an aberration or loss 
of sensation would point to the functional or structural alterations 
of the nervous apparatus devoted to the reception and transmission 
of sensational impressions; just as an aberration or cessation of 
respiration would point to a structural or functional alteration 
existing either in the nerves or in the apparatus of respiration. 
Whether the views of Prochaska and Gall, and of their followers, 
the phrenologists, be true or false, it would be nevertheless true 
that if the action of the intellect, when manifested by motions or 
sensations or consciousness, is always attended by chemical and 
physical changes of the nervous structures, then aberrated intel- 
lectual action would point to organic or functional changes in the 
nervous system. As in the case of aberrated motion and sensation, 
and of secretion and excretion, circulation and respiration, the 
causes of the aberration may lie entirely without the nervous sys- 
tem, in chemical and physical changes of the blood, induced by the 
catalytic action of morbific agents, so also in the case of aberrated 
intellectual action it may arise from chemical and physical changes 

ciation, 1857. Also, Essays on tlie Secretoiy and Excito-Secretory System of Nerves. 
By H. F. Campbell, M. D., Professor of Anatomy in tlie Medical College of Georgia, 
at Augusta, &c. PMladelphia, 1857. 

1 London Lancet (Amer. ed.), March, 1857. 



72 



OBSERVATIONS ON 



in the blood arresting or altering the normal chemical changes of 
the organs of the intellect. 

In all investigations into the causes and effects of disease, the 
pathologist should remember that the origin of the disease may be 
connected with derangements in the constituents of the blood and of 
all the organs, independent altogether of the nervous system." Thus 
in malarial fever the poison, whatever it be, destroys the blood- 
corpuscles, destroys the ferment in the blood which converts the 
animal starch elaborated in the liver into grape sugar, and produces 
profound alterations in the structures, blood, and secretions of the 
liver and spleen. Now, in the beginning, these effects may take 
place entirely independent of any alteration in the nervous system.' 
In this case the nervous system will be secondarily affected, and its 
action seriously disturbed, and this disturbance will give rise to a 
distinct set of phenomena ; but it is evident that the cause and 
origin of the disease lies back of this disturbance. 

The study of the physician does not cease with these phenom.ena. 

Whilst in the physical universe and in the structures of animated 
beings the phenomena are connected by determinate, definite rela- 
tions, in the moral world there is a disturbing element acting con- 
trary to all harmony. The history of the world presents a mournful ^ 
picture of a strife between two great antagonistic principles of good 
and of evil. Every individual that is born into this world forms 
a fresh battle-field for the conflict of these principles. In his pre- 
sent state, man resembles the ruins of a majestic temple ; those 
columns, though marred and broken, still retain enough of beauty 
and symmetry to remind us of its former grandeur; the inscription 
upon the wall of the innermost chamber, although covered with 
the damp and decay of ages, still points to a hand divine. The 
pleasant sentient emotions excited in the nervous system by bene- 
volent actions and the strict adherence to truth, prove that the 
cultivation of the virtuous affections is favorable to health. "While, 
on the other hand, the irritation, weakness, and morbid excitability 
of the nervous system produced by the indulgence of the evil 
passions, envy, jealousy, and revenge — the haggard countenance, 
the withered, blasted form of vice — prove that the indulgence of 
the principle of moral evil injures and wastes the body; prove 
that the intellectual and moral faculties act upon the material body 
by which they are environed ; prove that the material body may 
be rendered unfit for the normal exercise of the moral and Intel- 



MALARIAL FEVER. 73 

lectual faculties; prove that the knowledge of the physician should 
extend not merely to the physical, chemical, physiological, and 
pathological phenomena of the body, but should embrace the struc- 
ture of the intellectual and moral faculties, and their relations to 
the material body by which they are environed. 

It is evident, then, that the complete investigation of the origin, 
causes, effects, and treatment of disease demands an examination of 
the relations of man, during health and disease, to astronomical 
phenomena; demands an examination of the relations of man to 
the distribution of the terrestrial masses, to the soil, climate, and 
waters, not only at the present time, but in the past history of the 
relations of man to astronomical and terrestrial phenomena ; de- 
mands an examination of the structure and relations and alterations 
of the solids and fluids of all the organs and systems of organs, 
and apparatuses, and tissues, and blood, and secretions, and excre- 
tions; demands an examination of all the physical and chemical 
changes, and the relations of the physical, chemical, vital, and 
nervous forces; demands an examination of the relations of the 
physiological and pathological alterations of the nervous system to 
secretion, excretion, sensation, motion, and intellectual and moral 
actions. 

The pathologist and physiologist must necessarily be appalled 
by the immensity of the subject of his investigations ; and he is 
inevitably disappointed by the imperfections of human knowledge, 
and by the imperfections of the instruments and methods of in- 
vestigation. Thus, in attempting to account for the different mani- 
festations of only one disease, we have not, in the present state of 
science, access to the most valuable data, such as the relations of 
astronomical, terrestrial, physiological, and pathological phenomena, 
and in the vast majority of the subjects of disease the effects of 
original constitutions, previous habits, and previous disease cannot 
be determined and eliminated from the general mass of results. It 
is probable that the course of severe diseases is always modified 
by the constitution, diet, occupation, and previous habits, whether 
virtuous or vicious, temperate or intemperate, and by previous 
diseases, and by the relations of the individual and his ancestors 
to the soil and climate. Thus we know that in a body of strong, 
healthy men, exposed to precisely the same sources of malarious 
disease, we may have manifestations of disease from a slight febrile 
excitement, scarcely deviating from the condition of health, down 
6 



74 



OBSERYATIOXS OX 



to the most malignant type, commonly called congestive fever. If 
all have been alike exposed upon the same small ship, to the same 
poison, whence this difference? The difficulty and complexity of 
this problem, arising about a handful of mariners, may be compre- 
hended when we state that, amongst many other things, its solution 
would demand a knowledge of the previous history of the physical, 
chemical, physiological, and moral influences of soil, climate, and 
disease upon the ancestors, and even upon the races ; w^ould demand 
a knowledge of all hereditary tendencies, peculiarities of tempera- 
ment, and idiosyncrasy; would demand a knowledge of the relative 
activity and perfection of the individual organs and apparatus, and 
of the relations of these to each other; would demand a knowledge 
of the relations of the vital force to the matter of each organ and 
tissue and apparatus, and to the morbific agent or agents ; would 
demand a knowledge of the action and reaction of the morbific 
matter upon the different forms of organized structure, and the 
consequent derangement of the physical, nervous, intellectual, and 
moral phenomena ; would demand a knowledge of the relations of 
chemical action to the development of the physical and nervous 
forces, and the action of the intellectual and moral faculties; would 
demand a knowledge of the correlations of the physical, vital, nerv- 
ous, intellectual, and moral phenomena; would demand a knovrledge 
of the relations between physiological phenomena and the pheno- 
mena of the exterior universe. Every candid man will admit that 
the solution of such a problem is impossible at the present time, 
because the facts are wanting ; and they will long be wanting, 
owing to the extreme complexity of the phenomena. 

The imperfections of physiological and pathological investiga- 
tions are placed in a clear light when we reflect that physiologists 
and pathologists scarcely recognize the relations between the phy- 
sical, chemical, vital, and nervous forces ; are not acquainted with 
many chemical changes going on in the body ; know little or no- 
thing about the origin and offices of some of the most important 
constituents of the blood, that great source of the materials of 
structure and chemical change ; dispute about the offices of the 
spleen, supra-renal capsules, thymus and thyroid glands; and pos- 
sess no absolutely accurate method of analyzing the blood, or of 
determining the amount and character of the products thrown off 
from the lungs and skin. 

Whilst, therefore, w*e assert that the knowledge of pathological 



MALAEIAL FEYEE. 



75 



phenomena necessarily includes a knowledge of the relations of all 
the phenomena of the universe, and afQrm that the dignity and 
glory of a science should depend upon the multitude and com- 
plexity of its phenomena — whilst we express the hope that the day 
will come when the science of medicine shall be founded upon the 
immovable basis of inductive philosophy, and the world be com- 
pelled to recognize the truth that the solution of the problems of 
medicine requires a higher exercise of the reasoning faculties than 
the solution of the most complicated and difficult problems in phy- 
sical and chemical science, a higher exercise of the reasoning facul- 
ties than the solution of even the grandest problems of astronomy 
— we would acknowledge that these physiological and pathological 
investigations which we are about to present are imperfect in many 
respects, and are merely beginnings in the right direction. 

I shall be satisfied if they demonstrate the impossibility of the 
successful investigation of even the most striking phenomena of 
disease by a single individual, and lead to unity and concert of 
action amongst investigators. 



CHAPTEE III. 

THE BLOOD. 

Imperfect state of our knowledge of this fluid — Imperfections in our methods of 
analysis — Importance and difliculty of establishing a standard formula of the 
constitution of the blood in health — The composition of the blood varies, not 
only with the class, but with each species of animals, and corresponds with the 
development of the organs and apparatuses, illustrated by development of the 
blood and organs of invertebrate and vertebrate animals — Standard of Lehmann, 
and of Becquerel and Rodier — Importance of establishing the changes of the 
blood during thirst and starvation — Importance and difficulty of determining the 
amount of blood in the system. 

In the present state of physiological and pathological science, 
the investigation of the changes of the blood in health and in dis- 
ease is attended by great labor and numerous difficulties; and from 
the complexity of the substances, the number and delicacy and com- 
plexity of the chemical changes of these substances, and from the 



76 



OBSEEVATIONS ON 



numerous obscure and complex relations of these substances of 
the blood with the surrounding organs and tissues, and from the 
great imperfection of the methods and iustruments of investigation, 
absolute accuracy is impossible. In view of the great labor and 
numerous difficulties and imperfections and absolute failures neces- 
sarily arising from the great complexity of the substances and 
phenomena, and from imperfections in the modes and instruments 
of investigation, and from the partial and imperfect nature of all 
the results of investigation thus far recorded, the profession is com- 
pelled to view with consideration even approximations to the truth. 
These statements are dictated neither by a spirit of exaggeration, 
nor by a desire to avoid criticism or to crave indulgence. They 
are true, because important questions with reference to the origin 
and offices of the most important constituents of the blood remain 
unsettled and involved in obscurity. 

Whilst the physiological chemist knows that the elements of the 
blood are ultimately derived from the inorganic world (one portion 
directly and the other secondarily through the vegetable kingdom); 
whilst the chemist is able to investigate all the combinations and 
relations of these inorganic bodies out of the living organism ; 
whilst the physicist can demonstrate the correlation and establish 
the mechanical equivalents of the forces generated during these 
chemical changes ; while the physiologist can describe the general 
process of digestion, and the general superficial changes of the 
inorganic and organic materials during their preparation for the 
blood and structures ; whilst the physiological chemist can isolate 
many of the constituents of the blood, and of the secretions formed 
from the blood ; whilst the physiological chemist can isolate many 
of the substances resulting from the metamorphoses of the tissues 
and blood, and form plausible hypotheses with reference to the 
relations of these chemical changes to secretion, nutrition, and the 
development of the forces — still, the knowledge of the physiological 
chemist is incomplete, because numerous chemical changes have 
never been investigated, and his knowledge does not cover suffi- 
cient ground to allow the analysis, comparison, and generalization 
of all the physical, chemical, and physiological actions, or the de- 
termination of the origin, development, and metamorphoses, and 
physical, chemical, and physiological relations of each substance, 
or the determination of those fixed relations or laws by which it 
would be possible, not only to explain the correlation of the physi- 
cal, chemical, vital, and nervous forces, but also predict with abso- 



MALAKIAL FEVER. 



77 



lute certainty the effects of disturbances in the chemical changes 
and in the development and mutual relations of the forces. 

The imperfection of physiological and pathological science is 
placed in a clear light when we consider that the cause of the 
coagulation of the blood, the most striking and apparently simple 
phenomenon presented by this fluid, is still undetermined, notwith- 
standing the researches of Hewson, Hey, Prater, Hunter, Fordyce, 
Langish, Thackrah, Scudamore, Briicke, and Eichardson ; when 
we consider that the mode of origin and offices of fibrin are still 
matters of dispute, Zimmerman, Simon, and Inman considering it 
as an excretory product, of no further use in the animal economy, 
destined to be still further metamorphosed, and finally cast off, 
whilst Paget, Carpenter, and other physiologists regard it as the 
most perfect of the nutritious products destined to enter into the 
constitution of the organs and tissues ; when we consider that the 
mode and place of origin, and the offices, and the mode and place 
of death and disintegration and excretion of the colored blood- 
corpuscles are still subjects of dispute and investigation with the 
best physiological chemists ; when we consider that the mode of 
the formation of the secretions from the blood, and the connection 
of the nervous system with secretion, nutrition, and excretion, are 
undetermined, and are now engaging the attention of the best 
minds of the profession ; when we consider that the series of che- 
mical changes which the elements undergo during the nutrition of 
the organs and tissues, and during the development of the forces, 
are very imperfectly understood, if not wholly unknown ; when we 
consider that- the physical and chemical relations of the elements of 
the living body to the vast majority of poisonous compounds are 
unknown ; when we consider that physiological and pathological 
knowledge extends merely to the time and place, and results of 
change, and not absolutely to the nature of the changes themselves ; 
when we consider that no definite opinions prevail with reference 
to the relations of the physical, chemical, and nervous forces and 
phenomena with the vital and intellectual and moral principles. 
Should these imperfections in physiological and pathological science 
cause indolence and indifference ? Should the complexity of the 
phenomena, and the imperfections in the instruments and modes of 
analysis, lead the honest inquirer after truth to abandon the in- 
vestigation in despair? 

The honest attempts to unravel complicated phenomena, by 
honest and truth loving minds who are not afraid or ashamed to 



78 



OBSERVATIOXS 02^ 



point out their failures, and the imperfections of their modes of 
investigation, and who ardently desire to incite others to investiga- 
tion, and who would cheerfully destroy with their own hands every 
erroneous statement or hypothesis or theory which they have pro- 
mulgated, have been and will often be characterized by the para- 
sites and vultures of the medical profession, as failures, yea, even 
as dishonest failures, simply because they yield only negative results, 
or fail to elicit the whole truth. 

In judging of the value of original investigations, we should at 
all times bear in mind the fact, that the development of all sciences 
has been the slow result of the labors of many minds, and that the 
rapidity of the development of each branch of knowledge has been 
in exact proportion to the complexity of the phenomena. Thus 
mathematics, and astronomy and mechanics, which deal with the 
most simple and general phenomena, were the first developed, and 
are now the most perfect of all sciences. As man stands upon a 
pyramid, the foundation of which is the inorganic world, and the 
materials composing this pyramid, consisting first of plants in 
various stages of development, the simpler extending downwards, 
the more complicated extending upwards, diminishing in numbers 
as they increase in complexity; and secondly of animals in various 
stages of development, increasing in complexity and diminishing 
in numbers as they extend upwards ; and as the existence of man 
is absolutely dependent upon the relations of the component mem- 
bers of the universe; and as the forces of man are all the resultants 
of the action of the same forces of the sun which keep up a never 
ending circulation and change of the matter upon the surface of 
our globe ; and as the development and action and life of man and 
of all organized beings depend upon the forces not only of our sun 
but also of the fixed stars, it is evident that he is a type of the 
universe and comprehends within himself all phenomena, astrono- 
mical, physical, chemical, physiological and psychological, and that 
his phenomena are exceedingly complex, and require for their 
complete solution the most laborious investigations and the most 
exalted exercise of the reasoning faculties. Xotwithstanding, that 
from the complexity of the phenomena and the difiiculties of the 
investigations, the progress of physiology and pathology must be 
slow: the observer, so far from being discouraged, should be ani- 
mated to vigorous and prolonged efl:brt, remembering that every 
honest physiological and pathological investigation must be pro- 
ductive of good, even if its results be only negative. [N'egative 



MALARIAL FEVER. 



results are always valuable, because they assist in defining the 
bounds of knowledge, and in determining the extent of man's 
power over the phenomena of nature, which depends absolutely 
upon his knowledge of the properties, forces, and relations and 
laws of matter. 

Importance and Difficulty of Estahlishing a Standard Formula of 
the Constitution of the Blood in Health. 

The blood is composed of so many and such different materials, 
and is liable to so many variations from causes entirely compatible 
with health, that the establishment of a reliable standard to which 
the changes of the blood in disease may be referred, is difficult if 
not impossible, and requires nice discrimination, laborious investi- 
gation, and wide generalization. 

The blood is composed not alone of the elements of nutrition and 
secretion and force, it receives also the products of the disintegra- 
tion of the tissues and organs, and the products resulting from the 
chemical changes of the elements used in working the apparatus, 
and in maintaining a definite temperature. 

The elements of the blood may be furnished from the food and 
atmosphere alone, through the stomach, lungs, and skin; but the 
blood as blood, is the resultant of the elaboration of many organs, 
and of the chemical changes of all the organs and tissues. 

The blood is not only distributed by innumerable channels 
through every recess of the body ; the blood is not only the source 
of all the elements of structure ; the blood not only furnishes the 
materials for all the secretions and excretions, and for all the 
chemical changes — but the blood is in turn affected by the physical 
and chemical changes of every vessel, of every nerve, of every 
organ and texture of the body. It is evident, then, that the con- 
stitution of the blood will depend upon the food; upon the vigor 
and perfection of the organs of digestion, respiration, circulation, 
and secretion and excretion; upon the vigor and perfection of the 
nervous system, and of all the organs and apparatus; and upon 
the correlation of the physical, vital, and nervous forces. 

The character of the blood, then, will vary with the animal ; with 
the organ and tissue through which it is circulating; with the age, 
sex, temperament, race, diet, previous habits, occupation, and pre- 
vious diseases; with the soil and climate; and with the relative 
states of activity of the forces. 



80 



OBSEEVATIONS ON 



The constitution of the hhod varies not only with the class hut with 
each species of animals^ and corresponds with the development and per- 
fection of the organs and apparatus. 

Thus, in the lowest forms of the protozoa, which resemble simple 
cells provided with vibratile cilise, we find no circulatory system; 
no fluid separated from the albuminous fluid which permeates the 
structures, to which the name blood may be applied; no special 
organs; and no nervous system. In the higher members of this 
group we discover the first rudiments of a circulatory system, and 
an attempt at the interchange of the fluids from different parts of 
the body. All the stomatoda have contractile pulsatory cavities 
situated in the denser and outer layers of the parenchyma of the 
body. During their expansion these cavities become filled with a 
clear, transparent, colorless liquid, which disappears entirely during 
the contraction. No bloodvessels communicate with these cavities, 
and no special walls have been discovered surrounding them; and 
the fluid which they contain, although analogous to blood, contains 
no corpuscles. By these simple means, corresponding to the struc- 
ture of these animals, the fluids of the body are prevented from 
stagnation, and a free interchange of the nutritive elements pro- 
moted. 

In the polypi — inarticulate fleshy bodies, having a simple visceral 
cavity, with a single opening at the centre above, without intestines, 
without glands separated from the walls of the visceral cavity, with 
no distinction of sex, and an imperfectly developed nervous system 
in the highest, and none whatever in the lowest — the circulatory 
system is rudimentary, and the fluid which it distributes nothing 
but the digested matters of the visceral cavity mixed with sea- 
water. This circulatory fluid contains a few spherical corpuscles, 
apparently albuminous, and a few oil-globules. According to Dr. 
T. Williams,^ a few of these corpuscles appear to be nucleated, 
others appear to contain secondary cells, and others again are 
charged with minute granules. The fluid is incapable of coagu- 
lation, and contains albumen in very small amount. 

In the highest species of the acalephae the nervous system is 
more developed than that of the polyps, and the blood and circu- 
latory system show a corresponding degree of development. The 
transparent gelatinous bodies of these animals are traversed by 

' Memoir on tlie Blood-proper and Chylaqueous Fluid of Invertebrate Animals, 
by Dr. T. Williams, Philos. Transact., 1852 ; Brit, and For. Med.-Chir. Review, 
vol. xii. p. 484. 



MALARIAL FEVER. 



81 



canals, which receive water from the stomach or directly from 
without, and being lined with cili^ efiect a constant renewal of the 
water, and thus perform the office of a respiratory system. These 
aquiferous canals are surrounded by vessels which have exceed- 
ingly thin walls, and are without ciliated epithelium and longi- 
tudinal and circular fibres, and which open directly by large tubes 
into the alimentary canal. In some species, according to Will, 
these sanguiferous vessels contain a greenish fluid, with spheroidal 
an^ slightly elongated red corpuscles with large nuclei; in others 
the corpuscles are brown, and in others again they are of a greenish 
color. There is no regular circulation, the blood being shifted 
hither and thither by the irregular contractions of the body. The 
blood of the acalephse, although like that of the polyps, the direct 
product of digestion mixed with sea- water, is of a higher type, 
because its corpuscles are larger, contain more granules and oil- 
globules, and their cell-membranes are more distinct. 

The higher members of the echinodermata have a distinct circu- 
latory system separated from the alimentary canal, composed of 
arterial and nervous trunks, between which, in some species, there 
is an organ analogous to a heart. The echinodermata is the only 
class amongst the radiata in which a proper circulation of the 
nutritive fluid takes place, and this is attended with a correspond- 
ing development of the nervous and muscular systems and organs 
of secretion. It is in this class that we first find the liver in its 
rudimentary state, however, consisting of simple Ci:eca, opening 
into the digestive cavity. According to Dr. T. Williams, the cor- 
puscles resemble spherules, composed of hard and very minute 
granules of coagulated albumen, without any detectable nucleus or 
cell-wall, or oily particles, and are readily broken up into their 
individual molecules. 

In the spiunculida, the highest order of this class, the corpuscles 
are more highly developed, being flat and irregularly oblong, having 
small, bright, highly refractive nuclei. 

As the great object of these observations is to show that the 
constitution of the blood depends upon the development and per- 
fection of the organs, and apparatus, and nervous system, and place 
in a clear light the great difficulty and complexity of the problem 
to establish a definite standard to which diseased blood may be 
referred, we will pass over the remaining classes of the inverte- 
brata, and notice only the highest division of the mollusca, the 
cephalopoda. 



82 



OBSEEVATIONS ON" 



The nervous system of the cephalopoda is highly developed, 
having a central portion resembling the brain of the vertebrata, in 
the extraordinary increase of its ganglionic substance, and in being 
contained in a cartilaginous cranium. They have a well-developed 
muscular system, and the rudiments of an internal skeleton, and all 
the organs, except the spleen, which are found in the vertebrata. 
They have organs of sense corresponding in perfection with the 
development of the nervous system; digestive apparatus compli- 
cated in structure; salivary glands highly developed; a pancrfas 
present in some species; the liver present in all, and consisting of 
a compact glandular mass, with distinct excretory ducts ; kidneys 
also present. The circulatory and respiratory systems exhibit a 
development, and the blood shows an elaboration corresponding to 
the perfection of the organs and apparatuses of the cephalopoda. 
It coagulates spontaneously upon standing, and the number of 
corpuscles is greatly increased. They inclose numerous granules, 
thus resembling the colorless corpuscles of the vertebrata. The 
majority of the blood-corpuscles are colorless; some few, scattered 
here and there, have a violet hue. 

Blood of Vertebrate Animals. — In the amphioxus, or branchiostoma 
(Lancelot), the most simply constructed of vertebrate animals, the 
circulatory system resembles closely that of some of the Annelida, 
as the Eunice, in its division and the distribution of numerous 
pulsatile dilatations upon the different vascular trunks. The respi- 
ratory system is formed upon an equally degraded type. The 
branchial apparatus is placed in the same cavity in which are 
lodged the liver, kidneys, generative apparatus, and greater portion 
of the intestinal canal, thus resembling closely the invertebrata. 
The nervous and organic systems are correspondingly simple in 
structure. The canal which incloses the spinal column presents 
anteriorly no cranial expansion, but the spinal cord extends from 
one extremity to the other. The liver is reduced to its rudimen- 
tary condition, a greenish glandular layer lining a portion of the 
intestines, and the spleen is absent. Accompanying these simple 
undeveloped organs and feeble forces we find colorless blood, rich 
in water and poor in solid constituents. In the blood of this animal 
we find only colorless corpuscles. This is remarkable when we 
remember that the spleen also is absent. Colored corpuscles and 
a well developed spleen mark the more highly organized fishes. 



MALARIAL FEVER. 



83 



"We can assert that as far as our researches and experiments npon 
fishes have extended, the number of the colored blood-corpuscles, 
and the elaboration of the blood, and the rapidity of the develop- 
ment, and the energy of the forces, correspond to the development 
and perfection of the organs. Thus, in the Garfish (Lepisosteous 
osseus), which, in addition to branchial apparatus, has a capacious 
lung (opening by a short trachea and extending nearly the whole 
length of the abdominal cavity), we find a greater number of colored 
blood-corpuscles, and more active and vigorous forces. The G-ar is 
a destructive and active pirate, and consequently needs great mus- 
cular power to outstrip and capture the swift inhabitants of the 
watery elements. Without the simultaneous development of the 
colored blood-corpuscles, and of the organs and apparatus, this 
would be impossible. We might demonstrate these propositions 
by numerous examples obtained by our own laborious investiga- 
tions, but these will suffice to establish the truth of our propositions 
with reference to the class of fishes. 

In the class of reptiles we find a similar development ofHhe 
blood, corresponding to the development of the organs and nervous 
system, and the activity of the forces and intelligence. Thus, the 
blood of the doubtful reptiles, as the Congo Snake of our southern 
swamps and ricefields (Amphiuma means), and the Hellbender 
(Menopoma Alleganiensis), is thin, deficient in blood-corpuscles, 
and far less highly developed than the blood of the Alligator, or 
Chelonians. 

In Birds and Mammalia we find a great increase of colored 
corpuscles, not only in quantity, but also in numbers. The size 
of the corpuscles are greatly diminished. The character of the 
blood varies in the different species, and even with the same ; but 
the facts are as yet wanting which would enable us to introduce 
these elements with accuracy in the calculations destined to the 
establishment of a typical formula, to which the changes of the 
blood in disease may be referred. 

The following table, drawn up by Lehmann' from his own ana- 
lyses, and from the experiments and deductions of Schmidt, presents 
a comparison of the quantitative relations of the principal elements 
of the blood-cells and intercellular fluid : — 

^ Lelimann's Physiological Chemistry, English ed., vol. ii. p. 160: American 
ed., vol. i. p. 546. 



8-i OBSEEVATIOXS OX 



1000 Pakts of Moist Blood-Cokpuscles 


1000 Pakts of Liquok 


Saxguixis Cox- 






TAIN — 




Water 


6SS.00 


W ater . . . . 




Solid coustitiients . . . 


312.00 


SoUd constituents . 


. 97.10 


Specific gravity 


loss. 50 


Specific gravity 


. 102S.00 


Ha^matin . . . . 


1''.75 


Fibrin . . . . 


4.05 


VjlL'ULlliii clilLl L cIi--JXLciii Ui diit; • 


OQO -TO 


Albumen 


. 78.84 


Fat 


2.31 


Fat . . . . 


1.72 


Extractive matters . 


2.60 


Extractive matters . 


3.94 


Mineral siilistauces (without 




Mineral substances 


8.55 


iron) 


S.12 






Clilorine . . . . 


1.6S6 


Chlorine 


3.644 


Sulphuric acid 


0.066 


Sulphitric acid 


0.115 


Phosphoric acid 


1.134 


Phosphoric acid 


0.191 


Potassium • • . . 


o. o-^ 


Potassium 


0.323 


Sodium 


1.052 


1^ Ulll U.JLU. • • • • 


3.341 


Oxygen . . . , . 


0.667 


Oxygen . . . . 


0.403 


Phosphate of lime . 


0.114 


Phosphate of lime . 


0.311 


Phosphate of magnesia . 


0.073 


Phosphate of magnesia . 


0.222 


The following are the physiological limits of the variations of 


the constituents of the blood, as 


established by the researches of 


MM. BecquereP and Eodier : — 






In 1000 Part 


s OF Blood — 




The Water may vary 




from 760.000 to SOO.OOO 


'■ Specitic gravity of the hlood may vary 1055. ' 


• 1063. 


Globules 




•'' " 120.000 ' 


• 150.000 


Fibrin 


(I 


" 2.000 • 


3.500 


" Solid matters of the serum " 


" " 90.000 ' 


• 105.000 


'• Cholesterine 


it 


" 0.075 ' 


0.150 


Animal soap 


u 


" 1.000 ' 


2.000 


" Serolin 


il 


" " 0.010 ' 


0.030 


*' Chloride of sodium . 


(I 


« 2.000 ' 


5.000 


Soluble salts 


11 


" " 1.500 •' 


4.000 


Phosphates 


ii 


'•' 0.500 • 


• 1.000 



In 1000 Parts of Serum — 

The Specific gravity of the serum may vary from 1027. to 1032. 

" Water of the serum . . - SSu.OOO •• 900.000 

Solid matters . . . " " 100.000 120.000 

Albumen . . . " " 70.000 90.000 



The following is the typical formula of the constitution of the 
blood in health, adopted by MM. BecquereP and Rodier : — 

^ Pathological Chemistry of MM. Becquerel and Rodier, English ed., p. 90. 
2 Loc. cit., p. SI. 



:\IALARIAL FEVER. 



85 



Analysis of 1000 Parts of Blood. 
Specific gravity of the blood . 1060.000 

Water 781.600 

Globules .... 135.000 
Albumen .... 70.000 

Fibrin 2.500 

Fatty matters, extractive mat- 
ters, and free salts . . 10.000 
Pbospliates . . . . 0.550 
Iron 0.350 



Analysis of 1000 Parts of Serum. 
Specific gravity of serum . 1028.000 

Water 908.000 

Albumen .... 80.000 
Extractive matters and free 

salts 12.000 



Notwithstanding the results of these laborious investigations, we 
must acknowledge that the establishment of an absolute standard, 
expressing the constitution of the blood in health, is impracticable, 
if not impossible. In the first place, we must not only establish a 
formula for each class and species of animal, and for the human 
race generally, but we must establish a formula for each tempera- 
ment, and for each race and nation, under every conceivable cir- 
cumstance of soil, climate, and occupation. 

Another important field of investigation is the changes of the 
constituents of the blood during thirst and starvation. 

In almost all the forms and grades of fevers the patients are 
deprived of food, either by the physician or by the condition of the 
digestive apparatus. Accompanying this condition we have rapid 
chemical changes, and often perverted nutrition. The constituents 
of the blood may be divided into two great classes, the nutritive 
and force elements. From the chemical changes of these two 
classes arises a third class, called the excrementitious. ISTow, both 
classes of matter, the force elements and the nutritive elements, are 
consumed, chemically altered, and converted into excrementitious 
offending compounds during starvation. In like manner both 
classes are converted into excrementitious compounds in fever^ 
JSTow, to determine definitely what changes are due to fever, we 
must first determine what are due to starvation; that is, to the 
consumption of the blood during nutrition, and the generation of 
the forces by which the machinery is worked. This can only be 
accomplished by determining the changes of the blood during 
starvation, and the forces and products resulting from these che- 
mical changes. A standard will thus be established, to which the 
changes in fever may be referred. In fever we have a pathological 
state (abnormal changes) superadded to those normally existing. 
We can never have accurate pathological knowledge until we de- 
termine the physiological changes. Another difficulty meets us : 



86 



OBSEEVATIONS ON 



The elements of the blood are liable to variations, not only of 
quality, but also of quantity. We must determine, not merely the 
relative variations, but also the quantitative. By analyzing the 
phenomena carefully, and attributing to each its just position, we 
may eliminate the elements of the problem only to a probable 
issue, we may determine the character of the changes and of the 
m.orbific agent; but the absolute amount of these changes will be 
unknowD, without some method of determining the amount of 
blood in the system. Here, then, is a great and serious difficulty 
in the establishment of an absolute standard of comparison. We 
have no accurate means of determining the amount of blood circu- 
lating through the system. It is evident that obscurity on this 
point introduces obscurity everywhere, and impairs the value of 
every standard we may erect. The truth of this proposition is 
established by looking at the great discrepancies which have pre- 
vailed among physiologists, with regard to the amount of blood 
contained in the bodies of warm-blooded animals. Blumenbach 
estimated the quantity in an adult man at 8.5 to 11 pounds, Keil 
at 44, Haller computed it at 28 to 80, Borelli 20, Young 40, Du- 
mas 25, Fletcher 30, Ancell 80. M. Yalentin, by his method of 
injecting water, arrived at the following results. The numbers 
represent the relation existing between the quantity of blood and 
the weight of the body — 

Large dogs (the mean of four experiments), as . . . 1 : 4.5 

A lean, debilitated sheep, as 1 : 5.02 

Cats, female (tlie mean of two experiments), as , . 1 : 5.78 

A large female rabbit, as 1 : 6.20 

From these data he estimates the amount of human blood to be — 

Male sex, as 1 : 4.36 

Female sex, as . . . 1 : 4.93 

This would give in a man weighing 150 lbs. 80 lbs. of blood, 
and in a female weighing 180 lbs. 26 lbs. Lehman determined the 
amount of blood in the bodies of two criminals, who were decapi- 
tated, to be from 17.5 to nearly 19 lbs., or one-eighth the weight 
of their bodies. My own observations have established the fact, 
that the amount of blood varies with the different classes of animals, 
and corresponds with the rapidity of the chemical changes of the 
blood and tissues, and with the physical, vital, and nervous forces. 
These investigations have established that the blood is more abun- 
dant in warm than in cold-blooded animals. These facts are im- 
portant in their bearing upon the phenomena of health and disease. 



MALAEIAL FEVER. 



87 



When we have a large supply of blood, and a rapid distribution of 
blood, then we will have a rapid generation of force. 

In the present state of science we possess no method of deter- 
mining absolutely the amount of blood existing in the animal body. 
Whilst we might determine the amount of blood contained in the 
large bloodvessels, it would be utterly impossible to determine the 
amount in the capillaries, because the quantity lost after fatal he- 
morrhage is no criterion whatever, and the latter portions drawn 
are also mixed with the fluids of the organs and tissues. Our 
knowledge on this subject is vague, and may be summed up in a 
few sentences. The young are said to have more blood than adults 
and the aged, and lean persons are said to have more blood than 
very fat persons. As in certain diseases there is a rapid destruc- 
tion and perversion of the elements of the blood, and as it appears 
that these chemical changes are destined to fulfil certain salutary 
offices, as the destruction of peculiar poisons, it is evident that an 
increase or diminution of the blood, even within the limits of health, 
must modify not only the course of diseases, but also the action of 
remedial agents. The determination of an absolute standard is 
farther impossible, because in the piesent state of science the 
methods of analysis are not strictly accurate. We have no 
absolutely accurate method of determining the colored blood- 
corpuscles. 

We have stated these difficulties, not with the design of casting 
doubt and discredit upon physiological and pathological science, 
but rather with the design of pointing out the great complexity of 
the phenomena, and defining the bounds of knowledge, and induc- 
ing caution both in investigation and in the generalization of the 
results of observation and experiment. 



88 



OBSEEYATIONS ON 



CHAPTEE lY. 

CHANGES OF THE BLOOD IN MALARIAL FEVER, 

Color of the blood and sernm in malarial fever and other diseases — Specific gravity 
and coagulation of the blood in malarial fever and other diseases — Fibrin de- 
creases in malarial fever — Formation of heart-clots in congestive fever dnring 
life — Cause of the coagulation of the blood unknown — Chemical changes of the 
blood in malarial fever compared with the changes of the blood in other diseases 
— Blood-coi'puscles are destroyed during malarial fever, and during the slow 
action of the poison, unattended with fever — Principles of treatment founded 
upon these changes — Time when these changes of the blood commence. 

It is important that we should in the first place determine the 
extent and bearing of our means of investigation, and of our know- 
ledge. 

In the present state of physiological and pathological science, 
and methods of investigation, our knowledge of the changes of the 
blood during disease is limited to an examination of the venous 
blood of the extremities, or of the surface of the trunk. AYe have 
no means of investigating the changes of the blood in different 
organs and tissues during the different stages of disease. 

The changes of the blood in the different organs can only be 
determined by an examination of the blood remaining in those 
organs after death. The information yielded by an examination 
of the blood of the extremities and surface of the trunk during life, 
and of the blood remaining in the organs after death, must be 
imperfect, because we can only superficially determine the com- 
position of the blood at different stages of the disease, and are 
wholly unable to determine its changes in different organs and 
tissues, and apparatus, and are limited to an examination of the 
blood in the organs only after a fatal termination, and must, there- 
fore, remain without the facts which would enable us to determine 
definitely the various steps of the chemical changes, and the phy- 
sical, chemical, physiological, and toxicological action of the resulting 
compounds. The examination of the blood after death must always 
yield imperfect and unsatisfactory information, even with reference 
to the effects of the morbific agents upon the blood, immediately 



'malarial fever. 



89 



preceding death, because in the hours of death, when the circulation 
and respiration are impeded, and the temperature diminished, and 
the nervous and vital influences enfeebled, many physical and 
chemical changes of the blood may result from the disturbances of 
the circulation and respiration, and from the alterations of the pro- 
cess of endosmose, and from the chemical changes of the organs 
and tissues through which the blood passes, entirely independent 
of the actions of the morbific agents. 

In an examination of this kind it would be necessary first to 
establish a standard formula of the constitution of the blood in 
each organ, and tissue, and apparatus, by an examination of the 
blood after death, in the organs, and tissues, and apparatuses of 
those who had died in perfect health, and also during starvation. 
In the preceding chapter we demonstrated that the constitution of 
the blood varied with each animal, and in the human race varied 
with temperament, age, previous habits, diet, occupation, and pre- 
vious diseases and race ; and hence concluded that it was difl&cult 
if not impossible, to establish a universal typical formula of venous 
blood. It is evident, therefore, that the difficulties of establishing 
typical formulae of the constitution of the blood in the various 
organs, and tissues, and apparatuses, would be increased a thousand 
fold. 

Besides these difficulties, the poison or poisons which produce 
the changes of the blood in malarial fever have never been isolated, 
and we know nothing whatever concerning its physical, chemical, 
physiological, and pathological relations with the elements of the 
blood, and nervous system, and organs, and tissues by direct expe- 
riment. We can only infer them from the changes going on during 
the progress of the disease. So complicated are the phenomena, 
and so imperfect our knowledge of malarial fever, that we are un- 
able to answer such important questions as these: Does the poison 
act by catalysis, by its mere presence in the blood, inducing a series 
of chemical changes, which result in the alteration and destruction 
of the elements of the blood? or does it undergo chemical changes 
itself, and during these chemical changes generate from its own 
elements, and from those of the blood, substances capable of pre- 
venting and arresting the secretions of the organs, and of interfering 
with the nutrition and chemical actions of the muscular and nervous 
systems, and causing aberrated muscular and nervous actions ? Are 
the acceleration and disturbance of the circulation and respiration, 
and the aberration of the nervous and muscular phenomena, due to 
7 



90 



OBSERVATIONS ON 



the direct action of the poison in the blood upon the muscular and 
nervous elements, or to the action of the altered constituents of the 
blood? Are the changes in the secretions of the liver due to the 
direct action of the poison upon the secretory structures, or to the 
action of the altered constituents of the blood supplied for secretion, 
or to the action of the poison of the altered constituents of the blood, 
upon that portion of the nervous system which influences the secre- 
tion of the liver ? 

In attempting to answer these questions, we can reason analogi- 
cally, but not definitely and absolutely. The great difficulty is, 
that we have not as yet been able to isolate the poison. If we 
could isolate the poison, we would be able to watch its action, in 
combination with the actions of external agents, and compare its 
action with that of other known poisons upon the living system, 
under definite conditions. The relations of cause and eflfect could 
thus be determined, and the operation of the agents determined 
with a precision corresponding to the perfection of the modes of 
investigation. 

If the physical and chemical properties of a poison be known, 
and if it can be isolated and weighed, a definite quantity may be 
introduced into the animal body, and by carefully-devised experi- 
ments the physiologist can determine the channels through which 
the poison is absorbed into the blood, and its effects upon the tis- 
sues with which it comes in contact, and its chemical and physical 
relations to the elements of the blood, and the influence of the 
changes produced by it in the elements of the blood, upon the 
organs and tissues, and upon the development and correlation of 
the physical, and vital, and nervous forces; and by carefully- 
devised experiments the physiologist can determine whether the 
action of the poison be confined to one or more organs, and whether 
the derangement of the chemical actions in these organs may not 
be the cause of the subsequent phenomena ; and by careful ana- 
lyses of the excretions of the kidneys, intestines, skin, and lungs, 
he can determine in what state the poison is thrown off ; he can 
determine whether it has acted by its simple presence, or whether 
it has itself entered into the round of chemical change, and been 
either altered or destroyed ; and by a comparison of the products 
of the metamorphoses of the elements of the living body with the 
alterations produced in the poison, and in the constituents of the 
blood, he can form some definite, if not absolutely correct idea of 



MALAEIAL FEYEE. 



91 



the series of cliemical changes leading to the alterations of the 
various secretions and excretions, and of the elements of the blood; 
and by carefully-devised experiments the physiologist and patho- 
logist may also determine the relations of remedial agent to the 
poison. Upon the results of such experiments and investigations, 
a true, absolute system of pathology and therapeutics can alone be 
based. 

It is evident that the perfect knowledge of all diseases will never 
be obtained, until the physician is able to isolate the special poisons, 
and determine their physical, chemical, physiological, and patho- 
loo:ical relations. In the case of malarial fever, althouo^h analooical 
reasoning leaves no doubt in the mind that it is caused by the 
action of a special poison ; still we are compelled to admit that up 
to the present time this poison has not only never been isolated, 
but that v/e possess no known tests for its presence, except the 
peculiar class of phenomena induced by it in the living organism. 
We are compelled to admit that as we cannot isolate, weigh, and 
experiment with the malarial poison, we cannot with certainty 
trace the channels of its introduction into the blood, neither can we 
follow it through the course of the circulation, and determine its 
physical, chemical, and physiological relations to the elements of 
the blood, and secretions, and organs, and muscular and nervous 
systems ; nor can we tell the form and mode in which it is elimi- 
nated from the body. 

^Notwithstanding these imperfections of our knowledge, we can 
derive valuable information from the study of the symptoms, and 
of the changes of the blood, and secretions and excretions, and of 
the orga^ and apparatuses, and from a comparison of these with 
the analogous actions of those poisonous agents which can be iso- 
lated, weighed, and experimented with. 

Color of the Blood and Serum in Malarial Fever. — In severe cases 
of malarial fever I have observed that the blood presents, when first 
abstracted, a dark purple almost black color, and after exposure 
to the atmosphere the change from the venous to the arterial hue 
upon the surface of the clot is always slower than in normal blood, 
and in very severe cases it changes to a cherry-red color, and not 
to the bright red assumed by the surface of healthy venous blood. 

The blood found in the large veins after death always presented 
a deep purple and black color, and changed slowly to the arterial 



92 



OBSEEVATIONS ON 



hue upon the surface when exposed to the oxygen of the atmo- 
sphere. 

The blood of the liver presented a dirty brownish red and 
purplish red color, which did not change to the arterial hue when 
exposed to the oxygen of the atmosphere. The relations of the 
coloring matter of the blood to the oxygen of the atmosphere were 
noted in sixteen malarial fever livers, and in each instance the 
result was the same — no change of color. 

The blood of the enlarged, softened, slate-colored spleen of mala- 
rial fever, as far as my observations extend, presents reddish brown, 
and purplish brown, and purplish red colors, which remain un- 
changed during exposure to the oxygen of the atmosphere. 

The serum during the active stages of the severest forms of mala- 
rial fever was always, whether obtained from the surface of blisters, 
or from the blood of the capillaries, or from that of the veins and 
arteries, during life or after death, of a bright golden yellow color. 
I have demonstrated in several cases that this coloring was due, in 
part at least, to the coloring matter of the bile. Whether this 
change in the color of the serum be entirely due to the presence of 
the coloring matters of the bile, or to the presence of the products 
resulting from the decomposition of the colored blood-corpuscles, 
or to the simple increase of the normal coloring matter of the 
serum, has not as yet been determined. 

Specific Gravity of the Blood and Serum. — The specific gravities of 
both the blood and serum are diminished during the active stages 
of malarial fever, and during the slow action of the malarial poison. 
The following table will give a comparative view of the variation 
of the specific gravities of the blood in malarial fever and other 
diseases : — 



MALARIAL FEVER. 93 



Specific Gravities of the Blood and Serum in Various Diseases. 



OBSERVERS. 


DISEASES. 


KJiMAKKs. 


Specific 
gravity 
of blood. 


Specific 
gravity 
of serum. 


Bec(^uerel & Rodier 


Healthy Standard | 


Established by the examination of) 
the blood of 22 healthy persons J 


1055.0 

to 
1063.0 


1027.0 

to 
1033.0 




(( It 


Mean in the healthy male 


1060.0 


1028.0 


(( « 


tt tt ' ' 


Mean in the healthy female . 


1057.0 


1027.0 


Nasse .... 


ti ti ' ' 






ZimineriDaii . 


tt tt 








Josepli Jones . 


Malarial Fever 


Mean of 9 examinations of 9 men 


loss. 3 


1021.3 




Maxima of ditto .... 


1042.4 


1023.6 




it tt ' ' 


Minima of ditto .... 


1030.5 


1018.0 




it It 


Seaman ; intermittent fever of 12 d'ys 
Irish laborer; int. fever of 5 weeks 
Ditto, ditto of 6 weeks 


1042.0 


1018.0 






1034.0 








1030 5 


1021.3 


11 


it a ' ' 


Seaman ; severe remit, fev. 16th day 


1042.0 


1022.5 


i( 


it tt ' ' 


Ditto, ditto, 10th day 


1042.4 


1021.3 


u 


tt tt ' ' 


Remittent and typhoid fever, 11th d'y 


1035.0 


1021.0 


11 


it tt 


Remittent fever .... 


1042.4 




11 


tt it ' ' 


Intermittent terminating in congest- 










ive fever, 2 months 
Congestive fever .... 


1036.6 


1023.6 


11 


tt a 


1040.0 


1022.0 


Becquerel & Rodier 


Marsh C achext induced 






by Malarial Poison 


Mean of 5 cases .... 


10.36.7 


1021.2 


(< <( 


Maxima of ditto .... 


1040.5 


1024.1 




(( (( 


Minima of ditto .... 


1033.8 


1016.4 


(( It 


Typhoid Fever . 


Mean of 17 first bleedings 


1054.1 


1026 0 


(( u 




Mean of 6 second bleedings 


1051.4 


1024.8 


Guenaud de Mussy 








«Si M. Rodier 


Typhus Fever 


Mean of 6 cases .... 


1047.9 


1020.8 






Maxima of ditto .... 


1055 5 


1024.1 


U (( 


(( it 


Minima of ditto .... 


1041.2 


1020.0 


Becquerel & Rodier 


Ephemeral Fever . 


Mean of 8 cases .... 


1056.8 


1025.5 


Cholera 


In a man 30 years of age, bled on 










day of death . . , , , 


1074.1 


1042.2 


H it 


Acute Scurvy 


Man -IS years of age, 6 weeks . 


1050.3 


1025.5 


a it 


Chronic Scurvy . 


Man 32 years of age, 15 months 
Mean of 10 cases of symptomatic 


1060.3 


1026.2 


it It 


Anjemia . . . 










ansemia 


1049.9 


1026.8 


ti it 


Chlorosis 


Mean of 6 cases, females . 


1046.3 


1026.1 






Maxima of ditto .... 


1055 2 


1032.2 






Minima of ditto .... 


10.35.2 


1025.0 




Acute Bright's Disease 


Mean of 15 cases .... 


1048. 2 


1023.5 




Cachectic Dropsies . 


Mean of 16 cases .... 


1039.6 


1022.6 




Phlegmasi;e generally 






1027.0 




Acute Bronchitis . . 




1056.7 


1027.4 










1026.0 










1025.0 




Acute Rheumatism 






1025.0 



As far as the observations (whicTi are not only reliable, but 
present a condensed view of the most important results thus far 
recorded) presented in this table extend, they demonstrate that the 
specific gravity, or, in other words, the solid matters of the blood 
are more rapidly and decidedly diminished in malarial fever than 
in any other disease. 

Coagulation of the Blood. — In severe cases of malarial fever I have 
always observed that the clot is voluminous, and much less con- 
sistent than the clot of normal blood, or of the blood of the phleg- 
masise, and that the contraction of the fibrin is much less, and as a 



94 



OBSERVATIOXS OX 



necessary consequence the amount of tlie serum forced out is much 
less than in normal and in inflammatory blood. 

That the large size of the clot is due neither to an increase of 
globules, nor to an increase of fibrin, is conclusively demonstrated 



by the following tables: — 



TaUe o f the Blood- Corpuscles in 1000 parts of Healthy and 
JlalariaJ Blood. 



The blood-corpuscles in healthy Mood may rary from 

Mean of 9 examinations of the blood of 9 cases of malarial 

Maxima of ditto 

Minima of ditto 

Seaman : intermittent fever of 12 days 
Irish laborer ; intermittent fever of 5 Treeks. 
Ditto, ditto of 6 weeks .... 
Seaman ; severe remittent fever, 16th day 
Ditto, ditto, lOih day .... 
Eemitrent and typhoid fevers 
Eemitrent fever terminating in congestive fever, 2 vreeks 

Gonsestive fever 



Moist 
blood-cor- 
pascles. 


Water 
of moist 
blood-cor- 
puscles. 


Sv.lid 
matters 
of moist 
blood-cor- 
puscles. 


4S0.000 


360.000 


120.000 


to 


to 


to 


600.000 


450.000 


150.000 


331.397 


24S.54S 


S2.S49 


431.50? 


323 631 


107.320 




-'1 


.51.S12 






l.:''A431 






70.411 




1.50.S61 


51.S12 


401.764 


306. S23 


100.409 


431.. 5'? 5 


323.-^31 


107.320 


262. -r^ - 


: - ^36 


62.703 


30;'. 


~j'2 


73 65.5 


317 


-.217 


76.000 
S4.400 


343. ^72 


2o;.xi4 



ToMe of the Fibrin in 1000 jja-rts of Healthy and Diseased Blood. 



OB5EEYEE5. 



DISEASES. 



EEMAEKS. 



Andral & Gavarret ) 



Becqnerel Eodier 3 STA>a)ABD of Health ^ 
Joseph Jones . . , M.at.art.at. Eever 



Becqnerel iSodieri Maksh Cachexy induced 
I bv the Malarial Poisox 



Andral & Gavarret Typhoid Fe vee 



In healthy blood the fibrin may vary 
from ' 

Mean of 9 cases of malarial fever 
Maximtim of ditto . 
Minim am of ditto . 
I" t-rrr-il-ent fever of 12 days 

: vreeks 
- - : : ^eeks 
1. i-i- : fever of 16 days 
Ditto 01 10 days 

Eemittent and' typhoid fevers of 11 days 
Eemittent fever of 2 weeks 
Congestive fever 
j Ditto 

! Mean of 5 cases 
j Maximum of ditto . 
j Jlinimum of ditto . 
' Mean of 41 analyses 

Maximum of ditto 

Minimum of ditto . 



de 

-iier Typhus Fever 



I Andral & Gavarret Smallpox 



Becquerel & Eodier Ephemeral Fever 
Andral & Gavarret Scarlatlsa . . 



Measles 



Mean of 6 
Maximiun 
Minimum 
Mean of 5 
Maximum 
Minimum 
Mean of S 
Mean of 4 
Maximum 
Minimum 
Mean of 7 
Maximum 
Minimum 



cases 
of ditto 
of ditto 
cases 
of ditto 
of ditto 
cases 
cases 
of ditto 
of ditto 
cases 
of ditto 
of ditto 



2000 

to 
3.500 
2.018 
2.93S 

0. 577 
1.900 
2.. 540 

1. P25 
2.938 
1.433 
2.3S0 
2.710 
0.S77 
1.450 

3.390 
4.270 
2.360 
2.600 
4.200 
0.900 

2.466 
3 900 
I.21K) 
2 400 
4.400 
1.100 
2.S0O 
4350 
6.S00 
3.100 
2.742 
3.400 
2.400 



MALAEIAL FEYEE. 95 



Table of Fibrin in Blood — Continued. 



OBSERVERS. 


DISEASES. 


REMARKS. 




Becquerel k Rodier 


Acute Scurvy 


Man aged 48 years, sick 42 days . 


2.500 


" 


Man aged 21 years, sick 30 days . 


2.200 




Chronic Scurvy .... 


Man aged 32, sick 45o days . 


1.S50 




" .... 


Man aged 23, sick 552 days . 


1.320 


Popp 


Erysipelas 


Man aged 33 years 


6.600 


Andral & Gavarret 


" 


Mean of 8 analyses .... 


5.676 


" " 


" 


Maximum of ditto 


7.300 




" 


Minimum of ditto 


3.300 


"Wittstock , . . 


Cholera 


1 case 


11.000 




" 


Ditto 


11.000 


Becquerel & Rodier 




Man, day of death. .... 


l.SSO 






Ditto 


6..500 


Andral & Gavarret 


Phthisis 


Mean of 21 cases 


4.400 


" " 


" 


Maximum of ditto ..... 


5.900 




" 


Minimum of ditto ..... 


2.100 


Becquerel & Rodier 




Mean of 16 cases 


4.800 


Glover .... 


Scrofula 


Mean of 8 cases, males .... 


3 130 


Heller .... 


Carcinoma 


Mean of 7 cases 


4.915 


Becquerel & Rodier 


Bright's Disease, Acute 


Mean of 15 cases 


2.990 






Maximum of ditto 


3.760 






Minimum of ditto 


1 6.50 




Bright's Disease, Chronic 


Mean of 13 cases 


4.310 




Chlorosis 


Mean of 6 cases ..... 


4.200 






Mean of 10 cases .... 


3 720 


" " 





Maximum of ditto ..... 


5.820 






Minimum of ditto ..... 


1 620 


Andral & Gavarret 


Acute Rheumatism . . . 


Mean of 43 cases 


6.700 






Maximum of ditto 


10.200 


'((' w 




Minimum of ditto ..... 


2.800 




Chronic Rheumatism . . 


Menu of 10 cases 


3.800 , 


Becquerel & Rodier 


Puerperal Fever . . . 


Mean of 4 cases 


6.760 


Andral «Si Gavarret 


Pneumonia 


Mean of 58 analyses .... 


7.300 






Maximum of ditto 


10.500 






Minimum of ditto 


4 000 




Pleukitis 


Mean 


4.656 






Maximum 


5 900 1 


" " 




Minimum 


3.800 


Becquerel & Rodier 




Mean of 5 cases 


6.100 


Andral & Gavarret 


Angina Tonsillaris . . 


Mean of 6 cases 


5.550 






Maximum of ditto 


7.200 






Minimum of ditto 


3.800 


Becquerel & Rodier 


Acute Bronchitis . . . 


Mean of 4 cases 


4.800 


A.iid.r<il & GSiVfl^rrGt 




jMaximum of 6 cases .... 


9.300 






Minimum of ditto ..... 


5.700 


Becquerel & Rodier 


Phlegmasi.i; generally . 


Mean of numerous observations . 


.5.800 




Acute Bronchitis . . . 


Ditto, ditto 


4.800 






Ditto, ditto 


6.100 






Ditto, ditto, 1st bleeding 


7.400 






Ditto, ditto, 2d bleeding 


6.800 




Articular Rheumatism . 


Ditto, ditto 


5.800 : 



This table demonstrates: first, that the fibrin is diminished 
greatly in severe cases of malarial fever ; second, that the diminu- 
tion of this element of the blood is characteristic not only of 
malarial fever, but of all fevers (Andral and Gavarret), whilst its 
increase, on the other hand, is characteristic of the phlegmasise 
(Hunter). 

As a general rule, the diminution of the fibrin in malarial, as in 
the pyrexias generally, corresponds to the severity of the disease, 
provided there be no inflammatory complication. 

As far as my observations extend, the diminution and alteration 
of the physical properties of the fibrin in malarial fever, to any 
great extent, was always accompanied by congestions of the spleen, 



96 



OBSERVATIOXS ON 



liver, and braia, and serious cerebral disturbances. Whether these 
phenomena stand in the relation of cause and effect, cannot be 
determined simply by their association in a single disease, or in a 
class of diseases, independent of an investigation of the offices and 
relations of fibrin in health and in disease. 

These facts, with reference to the decrease of fibrin in malarial 
fever, are invested with interest and importance, in their agreement 
with the results of the investigations of Andral and Gavarret, and 
Becquerel and Eodier, in the changes of the blood in typhoid fever, 
and of Gnenaud de Mussy and Eodier, in typhus fever. 

The fibrin is not only diminished in malarial fever ^ hut it is altered 
in its properties and in its relations to the other elements of the bloody 
and to the lloodvessels. 

"We will illustrate this proposition by the following cases and 
post-mortem examinations : — 

Case illustrating the Physical Changes of the Fibrin, and the 
Formation of Heart- Clots in ]VIalarial Fever. 

Irishman — age 26; height 5 feet 11 inches; weight 170 pounds; 
black hair ; black eyes ; full, dark-brown beard and mustache. 
Limbs full and round, chest broad, and well developed. Has been 
in America (New York) nine years, and in Savannah three months. 
During this time he has followed the occupation of a baker. 

Sept. 11, 12 o'clock M.. 1857. Has just entered the Savannah 
hospital with remittent fever. Pulse accelerated but feeble, and his 
complexion shows the effects of malarial fever. Says that he has 
been sick for one week, and has been living near the depot of the 
Albany and Gulf Eailroad, in a low, malarious situation. Under 
the action of sulphate of quinia and stimulants, the febrile excite- 
ment disappeared in the course of four days ; the patient, however, 
Avas left in a very feeble condition ; complained of great weakness, 
his pulse w^as feeble, the action of the intellect sluggish, and he had 
a peculiarly disagreeable smell, which was not permanently removed, 
either by water or by a change of clothing. 

Under the action of tonics, he recovered sufficiently to walk 
nbout the yard ; but continued, however, weak, low-spirited, and 
indisposed to action. 

27th. Complained of torpor of the bowels. A mild cathartic 
was administered. 

28th. Has a cough. The wind has been from the northeast for 



MALARIAL FEVER. 



97 



some time, and the weather has been cold and damp, and epidemic 
catarrh is prevailing. About two-thirds of the hundred patients 
now in the hospital are suffering with the influenza. 

This patient was up and about the wards, assisting and nursing 
the patients all day. He was up and about when I went the 
rounds of the wards at 9 o'clock P. M. Shortly after this he com- 
plained of great oppression of the lungs, difficulty of breathing, 
and loss of muscular power. 

29th, 9 o'clock A. M. During the night took a sudden and 
remarkable change for the worse. 

Respiration spasmodic, and sounds as if the air cells, bronchial 
tubes and trachea contained large quantities of fluid, and is attended 
with a loud rattling sound in the throat. The churning, rattling, 
gurgling, crackling sounds of the lungs and trachea are very loud, 
and can be distinctly heard over the upper wards of the hospital. 
Muscular power completely exhausted ; lies upon his back, and is 
unable to turn upon either side. Surface of extremities cold; 
surface of trunk cool, several degrees below the normal standard. 
The temperature of the extremities does not differ essentially from 
that of the surrounding medium. The expression of his eyes and 
countenance, and his efforts to converse, show that he is intelli- 
gent; he is, however, entirely unable to articulate or expectorate. 

Sinapisms were applied to the extremities, epigastric region and 
chest, and stimulants were administered freely. These did not pro- 
duce any beneficial effects — did not arouse the circulation, and did 
not increase the animal temperature, because the supply of oxygen 
necessary for the chemical changes which generated the physical, 
muscular, and nervous forces, was cut off. The mustards scarcely 
reddened the skin, even after the application of several hours. 

The patient continued in this state, with a gradual diminution of 
power, until 1 o'clock A. M. the next morning, when the painful 
respiratory sounds were hushed in death. 

AUTOPSY EIGHT HOURS AFTER DEATH. 

Exterior. — Body in good condition, not emaciated ; limbs full 
and round; muscles of trunk and extremities covered by a thick 
layer of fat; face and hands sallow and sunburnt; surface of the 
skin which had been covered by the clothes, fair. 

Head. — Dura mater presented the usual appearance. Arachnoid 



98 



OBSEEYATIOXS OX 



membrane transparent and healthy, bloodvessels of pia mater filled 
with blood. 

"When the dura mater was removed, an ulcer in the substance of 
the brain was discovered, occupying a position near the centre of 
the superior surface of the left hemisphere of the cerebrum. This 
ulcer was three-fourths of an inch in length, half an inch in breadth, 
and one-eighth of an inch in depth. The w^alls w^ere thickened 
and much harder than the surrounding brain. The bloodvessels 
of the surrounding pia mater and brain w^ere congested with blood, 
and a small quantity of bloody serum w^as effused between the 
arachnoid and pia mater in the immediate neighborhood of the 
ulcer, but nowhere else. The appearance of the ulcer, and the 
congestion of the bloodvessels around, by no means accounted for 
the death of the patient. The thickened walls, the absence of pus, 
and the sound state of the structures of the brain around, show not 
only that the ulcer was of long standing, but also that it was rapidly 
healing. The existence of this ulcer will account, in part, for the 
dull, lethargic state of the intellectual faculties, but not for the 
death of the patient. 

The ventricles of the brain contained a small quantity of clear 
serum. 

The structures of the brain presented the usual consistence and 
appearance. 

Chest. — Heart normal in size; the right ventricle contained a large 
light yellow fibrinous clot, attached to the chordse tendineae and 
carneas columnse, and extended through the auriculo-ventricular 
opening into the auricle. This clot was firm in texture, and 
weighed one ounce. The left ventricle contained a small light 
yellow^ clot ; the aorta also contained a small, flattened, ribbon-like, 
light yellow clot. These clots v:ere evidently formed 'previous to 
deaths when the circulation icas exceedingly feeble. 

Lungs. — The lungs vjere greatly inflated^ and did not collapse in the 
slightest degree when air luas admitted into the pleura. They were 
congested ivith blood, and resembled in ap)pearance liver ; and when 
handled they were remarkably heavy, and felt more like liver than lungs. 
When cut, the air-cells, and large and small bronchial tuhes, were found 
filled icith serous fluid, and numerous fine bubbles of air. When the 
lungs were squeezed, pints of this serous fiuid flowed out. In many 
p)ortions of the lungs the serous fluid was clear ; in others it was reddish. 
The fluid resembled serum in all respects, and was not mucus. Here, 
then, we have the cause of the death of this imtient. He was drowned. 



MALARIAL FEVER. 



99 



Ahdomincil Cavity. — Stomach pale and perfectly healthy in appear- 
ance ; intestinal canal, from the stomach to the anus, pale and healthy 
in appearance. 

Liver. — The normal reddish-brown color of the liver was changed 
in most parts to a mixture of light bronze and light olive, and in 
several places resembled the normal color. In two circular spots, 
about three inches in diameter, the liver was of a dark-bluish slate 
color, like that of a recent case of malarial fever. The cut surface 
of the liver approached more nearly to the normal color than the 
exterior. The blood of the liver, after exposure to the atmosphere, 
assumed a red arterial color. It is evident from this examination 
that the structures of the liver were recovering from the effects of 
the malarial fever, and that the organ was regaining its normal 
color. 

Spleen. — Slate-colored, enlarged, and softened. The pulp of the 
spleen presented a dark purplish -brown color, which did not change 
to the red arterial color as rapidly as the pulp of healthy spleens; 
the change of color, however, was much greater than that of the 
pulp of the spleen in recent cases of malarial fever. This organ, 
like the liver, appeared to be recovering from the effects of mala- 
rial fever. 

Kidneys. — Healthy. 

We believe that we have now all the facts necessary for a rational 
explanation of the phenomena presented by this case. 

The malarious poison and its effects had produced profound 
alterations in the blood and capillaries, liver and spleen, and pri- 
marily by its direct action, or secondarily by the action of the 
•altered products in the blood, affected the sympathetic and cerebro- 
spinal nervous systems. The patient, although weak and lethargic 
on account of these pathological alterations and the ulcer upon the 
brain, was, nevertheless, in a fair way of recovery; the alimentary 
canal had resumed its healthy actions, and the liver and spleen 
were fast recovering, and he was gaining strength daily. We can, 
in view of these facts, safely assert that if no other disease had 
occurred, the lesion of the left hemisphere of the brain, and the 
effects of the malarial poison, would not have proved fatal. 

In this state of slow convalescence the patient was suddenly 
seized with the prevailing influenza. The mucous membrane of 
the bronchial tubes and air-cells was irritated. The irritation of 
the mucous membrane was followed by congestion of the blood- 
vessels and capillaries of the lungs. The capillaries were in an 



100 



OBSERVATIONS ON 



enfeebled state; the fibrin of the blood was diminished in quantity, 
and altered in physical and chemical properties ; the colored blood- 
corpuscles were diminished in number, and physically and chemi- 
cally altered ; the solid matters of the blood were diminished ; and 
the physical and chemical relations between the individual consti- 
tuents of the blood and the capillaries were disturbed. Healthy 
limited inflammation was impossible. Diffused inflammation of 
all the structures of the lungs resulted ; the serous portion of the 
blood poured into the air-cells, bronchial tubes, and trachea ; the 
supply of oxygen was in a great measure cut oft*; the chemical 
changes of the solids and fluids in a corresponding degree checked ; 
the physical forces, heat and electricity, and the nervous force, de- 
veloped by these chemical changes, were, as a necessary conse- 
quence, correspondingly diminished. 

The immediate cause of the death of this patient was a depriva- 
tion of oxygen and the retention of the carbonic acid gas. Wq 
may say with truth that he was drowned. 

Case illustrating the Changes or the Fibrin, and the Formation 
OF Heart- Clots in Malarial Fever. 

Irishman — laborer and boatman ; age 30 ; height 6 feet ; weight 
150 lbs. ; tall, spare frame, light hair, blue eyes; pale, sallow com- 
plexion. Has been running on flatboats and rafts, up and down 
the Savannah Eiver, between Savannah and Augusta, for the last 
twelve months. Habits irregular; addicted to the use of ardent 
spirits. Says that his constitution has suffered much from the 
exposure to the hot san and night air on the river, and also from 
the intemperate use of ardent spirits. 

September 20, 1857. "A flat, laden with wood, which he was 
bringing to the city, was sunk in shoal water." He was all day in 
the w^ater, up to his waist, fishing out the w^ood ; and at night had 
a chill, followed by fever. The fever went oft' before morning, and 
on the next day he was employed again in the water. The chill 
returned at night, and was followed by high fever. Has been sick 
from this time to the present time, September 27th, without any 
medical attendance. 

Pulse 106; respiration accelerated, labored; skin hot and dry; 
countenance distressed ; has a haggard, anxious look ; complains 
of great thirst, of pains in his back and bones, and of great exhaus- 
tion. His pulse, although rapid, is feeble, and his forces appear to 



MALARIAL FEVER. 



101 



be completely exhausted. His fever remitted slightly on the next 
day, but returned on the 29th inst. Under the action of large 
doses of sulphate of quinia, and stimulants, sinapisms, snakeroot- 
tea, and inilk-punch, and wine-whey, and brandy and arrowroot, 
the febrile excitement subsided, the urine regained its normal hue, 
and on the 4th inst. his pulse was 70, and respiration 18; tempera- 
ture normal, and function of skin normal ; and although apparently 
very weak, the patient was able to be up and about the ward. 

During this attack the saliva was acid, and the urine copious ; 
from 20,000 to 25,000 grains w^ere excreted daily. The specific 
gravity was correspondingly low, from 1012 to 1014. The abundant 
discharge of urine was due to the large quantities of water which 
his thirst led him to take, and also to the diuretic action of the 
infusion of snakeroot. Throughout the attack his pulse was feeble 
and his forces greatly exhausted, and he required close attention, 
and the free administration of stimulants. 

October 5th. This morning escaped clandestinely from the 
hospital. 

8th. Has returned. Pulse 120; skin hot and dry; respiratio.n 
accelerated, labored ; complains of great pain in the back of his 
head and neck ; these parts are swollen, and painful upon pressure. 
B. — Cold water dressing to back of head and neck. 

9th. His head has been shaved, and the tissues above the occi- 
pital bone, and above the left temporal and parietal bones, are 
swollen, and the skin looks black, and is ulcerated in several places. 
The swelling extends down along the neck, and reaches the supe- 
rior portion of the left shoulder. To the finger the swollen parts 
feel as if there was a collection of fluid beneath the skin. Says 
that he is suffering intense pain ; countenance distressed and hag- 
gard; pulse 128; skin hot and dry; respiration thoracic, labored, 
accelerated. 

10th. Pulse 160, feeble; skin hot; respiration spasmodic and 
labored. In addition to the intense pain in the back of his neck 
and left side of the head, he complains of intense pain in his chest. 
The pain in the chest cuts short the respiration, and renders it 
spasmodic. His countenance is expressive of great agony and 
terror. 

11th. Pulse 140, rapid and very feeble ; respiration 24, labored, 
thoracic, spasmodic. The pain in his chest is intense ; he groans 
and cries at every breath* and the expression of his countenance is 
indicative of great agony, terror, and horror. Was restless and 



102 



OBSEEVATIOXS ON 



delirious during the night, and during his delirious visions spoke 
and acted as if he was engaged in mortal combat. Has no hope of 
himself, and refuses all medicine. The back of his neck and side 
of head is much swollen, and when pressed with the hand there is 
a distinct fluctuation. Hoping that discharge of the pus, or fluid, 
would afford relief, a free crucial incision was made at the most 
prominent part of the swelling. Nothing but blood issued. The 
hemorrhage was so great, that it was necessary to check it by the 
application to the wound of a compress, saturated w^ith the tincture 
of muriate of iron. 

12th. During the night was delirious ; would rip out the most 
terrible oaths, and cry out that the devils were after him, had 
beaten him severely, and were endeavoring to throw him out of 
the windows. At other times he would speak and act as if he had 
been in mortal combat, and was wreaking vengeance upon an 
imaginary antagonist. These actions excited the suspicion that 
the injury on the back and side of the head was received from a 
blow. 

The patient died at one o'clock A. M. this morning. 

AUTOPSY NINE HOURS AFTER DEATH. 

Exterior. — Body much emaciated; back and left side of neck 
much swollen. The inferior surface of the trunk and neck pre- 
sented a mottled appearance, from the settling of the blood by 
gravitation during the last hours, when the circulation was feeble. 
On the right leg there were the marks of an extensive ulcer upon 
the skin covering the tibia ; the cicatrix presented a purplish, angry 
color. When incisions were made into the swollen parts of his 
neck, and back and side of head, the spaces between the muscles, 
the meshes of the fibrous tissue surrounding and connecting toge- 
ther the muscles and the fibrous tissue of the skin, were found to 
be completely filled and distended with golden-colored serum. 

Head. — Dura mater healthy. Arachnoid memhrane transparent 
throughout its entire extent over the hemispheres of the brain. At 
the base of the brain it was slightly opalescent. 

Bloodvessels of pf« mater not more filled with blood than usual. 

The cortical and medullary substances of the cerebrum, and of 
the cerebellum, and the structures of the pons Yarolii, the medulla 
oblongata, and superior portion of the spinal marrow, appeared 
natural in consistence and color. 



MALARIAL FEVEE. 



103 



Yentricles of brain contained f5iv of golden colored serum. 

The superior longitudinal sinus of the dura mater contained a 
golden-yellow elongated clot, the diameter of which was about one 
half that of the longitudinal sinus. 

Chest. — Heart somewhat enlarged. Pericardium contained f of 
golden serum. All the cavities of the heart contained golden- 
colored clots. The right auricle had a large golden-colored clot, 
which was attached to the carnete columnss and chordse tendineae 
of the auriculo-ventricular valves. The aorta, carotids, and pulmo- 
nary arteries contained elongated golden-colored clots, having dia- 
meters nearly equal to those of the arteries. All these clots were 
firm and elastic. 

Lungs. — The lungs did not collapse when the cavity of the chest 
was opened. Exterior surface of the pleura covering the lungs 
and lining the walls of the thorax was covered with soft coagulable 
lymph of a golden-yellow color. Adhesions were numerous, but 
as yet not strong, on account of the soft, fresh condition of the 
coagulable lymph, which was evidently but recently effused, pro- 
bably within the last seventy hours. This inflammation of the pleura 
accounts for the severe pain in the chest during life. The lungs 
were much congested with blood, and when cut they resembled 
liver. The bronchial tubes and air-cells contained much serum. 
This serous fluid poured in large quantities from the cut surface. 

The anterior surface of the middle lobule of the right lung had 
a dark blackish-red spot, about one inch in diameter, which resem- 
bled at first sight a wound from a sharp instrument. An examin- 
ation of the exterior of the chest, and interior surface of the ribs, 
showed neither wound nor fracture of the ribs. When closely 
examined, this portion of the lung was found to be more congested 
and solidified than the surrounding portions, and would in all pro- 
bability, if the patient had survived, been the seat of an abscess. 

AMominal Cavity. Alimentary Canal. — The stomach, although 
enormously distended with gas, was pale and healthy in appear- 
ance ; small intestines also pale and healthy, to the naked eye. 

Liver of a light bronze color. The color is lighter than that of 
the liver in the active stages of malarial fever, but resembles the 
color of a liver which was recovering from the effects of malarial 
fever. Cut surface of a light bronze color, and not of such a deep 
and decided bronze as the liver of the active stages of malarial 
fever. The right lobe of the liver had upon its under surface a 
slate-colored spot three inches in diameter, which resembled in all 



104 



OBSEKVATIONS ON 



respects the liver of a recent case. AVhen an incision was made 
across this spot, the cut surface presented for one-sixth of an inch 
the true malarial hue ; below this it approached more nearly the 
normal hue. The structures of the liver did not appear to be 
softened. 

Spleen. — Much enlarged, of a dark-slate color, and although much 
softer than a normal spleen, it was much harder than a spleen of a 
recent case of malarial fever. Weight 31 ounces. This organ, like 
the liver, appeared to be just recovering from the effects of malarial 
fever. Kidneys appeared to be somewhat enlarged ; the calices? 
infundibula and pelvis of the kidney contained a fluid resembling 
pus. 

The following appears to be the cause and history of this last, 
attack : — 

The patient left the hospital when he was in an exceedingly 
feeble condition, after a severe attack of remittent fever. It is 
probable that he indulged his taste for ardent spirits, for the day 
on which he left the hospital was election day. The wind was 
from the northeast, and the weather damp and cool, with occasional 
scuds of rain and mist. Exposure to this cool damp wind, fresh 
from the ocean, and the low grounds and swamps of Georgia and 
South Carolina, not only during the day but probably during the 
night also, in a state of intoxication, induced a severe attack of 
pleuro -pneumonia. 

The swelling on the back of his head was due either to a blow 
or to inflammation in the cellular tissue and muscles analogous to 
the inflammation of the lungs, and probably arising from the same 
cause. 

The large amount of serum effused into the bronchial tubes — the large 
amount of golden- colored serum effused into the cellular tissue of the 
nech and head — and the large golden^ fibrous clots in the heart and arte- 
ries — the settling of the blood in the most dependent parts of the body — 
tlie app)earance of the cicatrix^ and the inflamed spot in the lungs, all 
indicated disturbances in the constitution of the fibrin, and of the relations 
between this element and the other elements of the blood to each other, and 
to the bloodvessels and capillaries. 

The occurrence of the fibrous clots in the heart and bloodvessels 
during malarial fever, demands a careful investigation. 

As fo.r as my observations extend, the formation of heart-clots during 
life is very comtnon in malarial fever. 

In fifteen post-mortem examinations I found heart-clots in ten 



MALAEIAL FEYEK. 



105 



cases, and of the remaining five, one was a case of tjplioid fever 
combined with remittent fever, another was a case of malarial fever 
of long standing, where the patient died of exhaustion, and in the 
remaining three no special examination for heart-clots was insti- 
tuted. The following cases, in addition to the two just reported, 
will illustrate the symptoms attending the formation and existence 
of these heart-clots : — 

Fatal Case of Congestive Fever, terminating suddenly — Fibrin- 
ous Concretions in the Heart and Pulmonary Bloodvessels, and 
Aorta. 

Irish laborer; height 5 feet 10 inches, weight 150 pounds; black 
hair, black eyes, dark complexion, resembles an Arab in appear- 
ance ; person, dirty and filthy. 

Sept. 2d, 1857, 12 o'clock M. Has been sick, on the bay, for ten 
days, with an abscess in the palm of his hand ; previous to this 
he had been working on the river bank. 

When first brought (this morning) into the hospital, he appeared 
stupid, and urinated in the bed. After the administration of a 
hot bath, and the lancing of his hand, he was aroused, and now 
appears to be entirely restored to the exercise of his intellect. 
Seems to be very weak, and complains of no pain, or trouble any- 
where, except in the palm of his hand. Skin not warmer than 
usual ; tongue dry, red, and glazed, and harsh and rough to the 
touch; pulse 82. 

Continued sensible, and apparently convalescent, and complained 
of nothing, and manifested no striking phenomena until Sept. 3d, 
31 o'clock P. M. 

At this hour I was summoned hastily, and found this patient 
insensible, with his mouth open and groaning loudly at every 
breath. His groans sounded very much like the barking of a dog. 
Countenance distressed, anxious, and expressive of great agony ; 
tendons twitching violently; teeth coated with sordes; tongue dry, 
red and glazed, and harsh to the feeling. Eespiration 40, thoracic, 
panting; pulse 104. Temperature of hand 103° P. Skin hot, dry, 
and rough. When the attempt is made to arouse him, by violent 
shaking and loud talking, he mutters incoherently. Great tender- 
ness upon pressure of epigastrium ; cries out whenever this region 
is pressed. Cups to the temples and back of neck, a large blister 
over the epigastric region — sinapisms to the extremities, stimu- 
8 



106 



OBSERYATIOXS ON 



lants and sulphate of quinia, all failed to arouse this patient, and 
he died twenty hours after this observation. 

There was but little change in the symptoms, with the exception 
of an increase in the frequency of the respiration and pulse. 

AUTOPSY THREE HOURS AFTER DEATH. 

Head. — When tlie skull-cap was removed, the dura mater pre- 
sented the usual appearance. Serous effusion had taken place be- 
tween the dura mater and membranes, and surface of the brain, 
fsiij of bloody serum flowed from the base of the brain, and there 
had been an effusion of golden colored serum between the arach- 
noid and pia mater. Bloodvessels of pia mater filled with blood. 
Bloodvessels at the base of the brain, and upon the medulla oblon- 
gata and spinal cord, more engorged with blood than those upon 
the superior portions of the brain. This was, without doubt, due 
solely to the effect of gravity. The substance of the brain pos- 
sessed the usual consistency, and appeared to the naked eye to be 
normal in structure. 

Chest. — Lungs normal; trachea filled with froth. 

Hearty normal. The right auricle contained a large golden-co- 
lored clot, which filled almost the entire cavity. The left auricle 
contained several small yellow clots. 

The right ventricle contained several small clots of blood, which 
resembled, in all respects, coagulated blood. 

The main trunk of the pulmonary arteries contained a long, 
flattened, ribbon-like, yellow clot, which extended not only through 
the large trunk, but divided and sent off branches to each branch 
of the pulmonary artery ; and then again subdivided and sent 
branches off' to the minor branches of the arteries. When the 
main clot in the pulmonary artery was gently pulled, the branches 
were drawn out twelve inches in length, and at their extremities 
were not much larger than a fine silk thread. The clot was almost 
entirely free from red corpuscles, of a yellow color, firm, and elas- 
tic in structure, and in appearance resembled an organized product. 

A similar ribbon-like, yellow, elastic clot, extended through the 
whole length of the aorta. The blood in the vena cava was coagu- 
lated, but the coagulum was like that of ordinary blood, and much 
less firm than the clots of the right auricle, pulmonary arteries, and 
aorta. 

Abdominal Cavity. — The liver presented the true malarial hue; 
contained no grape sugar, but an abundance of hepatic starch ; and 



MALARIAL FEVER. 



107 



its blood did not change to the arterial hue when exposed to the 
atmosphere. The spleen was enlarged, softened, and of the slate- 
color of malarial fever. 

Stomachy intestines and kidneys normal. 

The autopsy demonstrated this to he a case of malarial fever. 

Case of Congestive Fever illustrating the roRMATioN of Fibrin- 
ous COAGULA IN THE HeART AND BLOODVESSELS. 

Irish seaman, aged 24; light hair, light blue eyes, fair complex- 
ion; height 5 feet 7 inches; stout, well built, weight 150 pounds. 

Oct. 12th, 1857, 12 o'clock M. Entered the hospital two hours 
ago. Now, he is out of his head, and can give no history of his 
case. A companion states that he has been watching at night on 
board a brig, lying in the river, below the ship-yard, along the low 
marshy shore of the Savannah Eiver, and that he was taken sick 
with chill and fever one week ago, but did not, until two nights 
ago, discontinue watching at night. Habits intemperate. 

Pulse 137, rapid and feeble; respiration 32; skin, hot and dry. 
Tip of tongue clean, and of a bright red color — the remaining por- 
tion of the tongue is coated with yellow fur. The tongue is dry 
and harsh to the touch, and feels, when the fingers are passed over 
it, like sand-paper. The patient mutters to himself continually, 
half-formed sentences and imperfect words. Continues to mutter 
in the same incoherent manner, notwithstanding strenuous efforts 
to arouse and attract his attention. About one hour ago his ex- 
tremities felt cooler, and his pulse was more feeble than it is now; 
mustards were applied to the extremities — they increased the tem- 
perature and rendered the pulse somewhat fuller, and aroused his 
intellect for a moment, but he again relapsed into the state of de- 
lirium. 

Mustards to the epigastrium and extremities, cut cups to the 
temples and back of neck, stimulants and sulphate of qninia and 
purgatives, failed to arouse the intellect, and at 8 o'clock P. M., 
the patient lay in a profound stupor, w^ith full rapid respiration 
and full rapid pulse. Pulse 124, and has increased in force and 
volume under the action of the stimulants and sulphate of quinia. 
Skin hot and dry ; tongue presents the same dry and rough ap- 
pearance. R. — Continue the stimulants and sulphate of quinia, and 
apply blisters to the back of the neck and over epigastric region. 

13th, 11 o'clock A. M. The cut cups to the head, the sinapisms 



108 



OBSEEVATIONS O^f 



upon the extremities, the blisters upon the back of the neck and 
epigastric region, and the diffusible stimulants and cathartic have 
failed to arouse this patient, and he now lies in a comatose state, 
and passes his urine and feces in the bed. The nurse states that 
during the night, he was much more restless than at the present 
time, and it was necessary to give constant attention that he did 
not fall out of the bed. The medicine has operated freely, and the 
blister has drawn well. The serum from the blistered surface is 
of a golden color. 

Eespiration 30, stertorous. The patient lies in a stupor, with 
his eyes shut and mouth open, and emits a suppressed groan, or 
whine, at every breath — his appearance, and the sounds which he 
emits, are similar to those of the patient described in the preceding 
case. These groans appear to be entirely involuntary, and depend 
upon the state of the organ of voice, and the mode in which the 
air passes through it. 

Pulse 144, feeble. The sounds of the heart cannot be distin- 
guished — they are both united into one, and the heart makes a 
short, quick, thumping sound. The number of the thumps of the 
heart corresponds to the pulse, 144 to the minute. Temperature 
of atmosphere 77° F. ; temperature of hand 103°.5, temperature in 
axilla 104°. 5. Skin hot and dry ; teeth coated with sordes. Can- 
not get a sight of his tongue, as his teeth are tightly closed, and he 
is entirely insensible. 

I have just applied mustards to his extremities — they do not 
arouse him — after remaining on one hour they scarcely redden the 
surface. 

9 P.M. Profound coma; respiration thirty-two, spasmodic; pulse 
is gone; heart merely flutters ; head and trunk warm, extremities 
cold. Have again applied mustards to the extremities, and admin- 
istered difiusible stimulants, but they do not produce the slightest 
effect, and he will die in the course of one hour. 

The patient died half an hour after this observation. 

AUTOPSY TWELVE HOURS AFTER DEATH. 

Body in good condition, apparently not at all reduced; limbs 
full and round, muscular, well developed; complexion fair, with a 
slight tinge of yellow; skin of the dependent portions slightly 
darker than that of the superior portions of the body; rigor mortis 
remarkably strong ; it required all the force that I could exert to 
straighten his arms, and they would return back to the bent posi- 



MALAEIAL FEVEE. 



109 



tion with considerable force ; after the right arm had been straight- 
ened out at right angles to the body, and while I was standing 
between the arm and the body, engaged in opening his abdomen 
and thorax, I felt the pressure of a hand and arm upon my back — 
this was the hand of the dead man, which had slowly returned to 
its former position by the contraction of the muscles. 

Head. — Dura mater normal in appearance; the longitudinal sinus 
of the dura mater contained an elongated^ flattened^ rihbon-like, fibrinous 
clot^ which was free from colored hlood- corpuscles^ and of a yellow color. 
This^ without doubt, was formed before death. Arachnoid membrane 
opalescent, pearl colored in many places ; bloodvessels of pia mater 
filled with blood. The substance of the brain appeared to be 
normal in color and texture, as far as an examination with the 
naked eye extended; it was perhaps a little softer than usual, but 
this may have been due to post-mortem changes, and at any rate 
would not account for the symptoms during life ; ventricles of the 
brain contained no serum ; bloodvessels of medulla oblongata and 
superior portions of spinal cord not congested with blood. 

Chest. — Exterior surface of the heart adherent at all points to the 
pericardium. There was no free space between the heart and the 
pericardium, hence no fluid lubricated the heart. If this lesion 
was the result of inflammation, it is certain that the inflammation 
had nothing whatever to do with the present attack of fever. 
Muscles of the heart paler than usual. The right auiicle and ven- 
tricle contained a yelloiv clot, free from colored blood- corpuscles, ivhich 
was attached to the columnoe carnece, and chordce tendinece of the right 
ventricle, and extended through the auriculo-ventricular opening into the 
auricle. This clot sent off a large branch into the pulmonary artery. 
This branch of the yellow fibrinous clot, which almost completely filled 
up the pulmonary artery, subdivided and sent branches down the right 
and left pulmonary arteries, and these branches again divided and sub- 
divided into numerous branches, the smallest of which were not larger 
than fine threads. These fibrinous threads passed deep into the blood- 
vessels of the lungs, probably almost to the commencement of the capil- 
laries. The left ventricle contained a similar yellow fibrinous formation 
almost entirely free from colored blood corpuscles, which was attached at 
one extremity to the colum,nce carnecB, and chordce tendinece, and extending 
through the auriculo-ventricular opening into the auricle, subdivided 
into branches, which passed up the pulmonary veins, and subdivided 
into numerous smaller branches which occupied the smaller divisions of 
the pulmonary veins. These fibrinous bodies of the pulmonary veins 



110 



OBSEKVATIOXS OX 



and arteries luere very elastic — with care they could he drawn out of the 
smaller branches of the pulmonary veins and arteries^ four and six 
inches in lengthy without breaking^ notwithstanding that the smallest 
branches were very delicate. The aorta contained a similar clot. All 
these clots were of a bright yelloio color^ alvwst entirely free from colored 
blood- corpuscles^ and presented almost an organized appearance^ and 
were^ without doubt^ formed long before death. 

The large nervous trunks were distended with partially coagu- 
lated black blood; the heart, arteries, and pulmonary veins con- 
tained little or no blood. 

When the black blood from the large venous trunks was exposed 
to the atmosphere, it assumed slowly and imperfectly the arterial 
hue. The blood appeared to have been collected in the capillaries 
and veins. If the chemical changes between the colored blood- 
corpuscles and liquor sanguinis, and between the blood-corpuscles 
and the capillaries, and the structures and fluids surrounding the 
capillaries, be arrested, as a necessary consequence the circulation 
of the colored blood-corpuscles through the capillaries must be 
greatly interfered with. 

Lungs. — Normal in appearance and structure; lower (dependent) 
portions coDgested with blood. This was due to the action of gravi- 
tation. The trachea, bronchial tubes, and air-cells contained much 
froth. 

Abdominal Cavity. — The mucous membrane of the stomach pre- 
sented to the naked eye no marks of inflammation or pathological 
alteration. 

The mucous membrane of the small intestines presented a darker 
color, the bloodvessels appeared to be more congested with blood 
than usual, but there were no marks of inflammation, and the con- 
gested state of the vessels appeared to be entirely due to the action 
of the cathartic. 

Liver. — The liver presented a much darker color upon its exterior 
than normal, but not the dark slate color of cases of malarial fever 
of longer standing. When incisions were made into the liver, the 
cut surface was different in appearance from that of the healthy 
liver, and approached the bronze color of malarial fever. The 
color of the cut surface, however, was several shades lighter than 
that of malarial fever of longer standing. Oq the under surface of 
the right lobe were several spots of the dark slate color peculiar 
to malarial fever. The liver- cells presented the usual appearance. 



MALARIAL FEYER. 



Ill 



In some cases they, as well as the tissues around, appeared to con- 
tain more oil-globules than usual. 

The liver contained animal starch without a trace of grape sugar. 

Spleen enlarged, softened, disorganized, and of a dark slate ma- 
larial color; when pressed gently between the fingers, the trabeculae 
could be felt giving way. After eight hours' exposure to the atmo- 
sphere, small streaks, inclining to an arterial hue, appeared upon 
the cut surface of the spleen, and probably were due to the change 
in the blood which issued from the divided vessels. 

The dark effused blood of the spleen was found under the 
microscope to consist of colored and colorless corpuscles and dark 
granules; some of the colored corpuscles were swollen, and altered 
in shape. The alteration was by no means universal or .remark- 
ably great. 

Kidneys. — This subject had but one kidney ; this corresponded 
to the right kidney. The inferior surface of the kidney presented 
a dark slate-colored spot, two inches in diameter; the color of the 
spot resembled in all respects the slate color of the malarial fever 
liver. When an incision was made into the substance of the kid- 
ney, through this slate-colored spot, the cut surface presented a 
bronze color to the depth of about one sixth of an inch. The 
bronze color gradually shaded into the normal color of the kidney. 
With the exception of this slate-colored spot, the color of the kid- 
ney was normal. 

After a careful examination of the symptoms and the patholo- 
gical alterations presented by these two cases of congestive fever, 
it appears that, with the exception of the heart-clots, we do not 
discover any pathological changes of the cerebro-spinal nervous 
system, and of the organs, which of themselves would account for 
the sudden severity of the symptoms, or the death of the patient. 

As far as an examination with the eye extended, we did not dis- 
cover in the brain any structural alterations sufficient to account 
for the sudden and alarming symptoms of delirium and coma. We 
should not, however, in the present state of chemical, physiological, 
and pathological science, decide dogmatically a question of such 
importance, for we are wholly ignorant of the chemical, physio- 
logical, and pathological relations of the malarial poison to the 
nervous elements. It is evident that a thorough knowledge of the 
phenomena of malarial fever demands, amongst many other things, 
a thorough knowledge not only of the appearance and chemical 
constitution of the structures of the cerebro-spinal and sympathetic 



112 



OBSERVATIONS ON 



nervous systems, but also a thorough knowledge of the physical, 
chemical, and pathological alterations of these structures, when 
acted on by morbific agents. 

Whatever were the alterations of the nervous elements in this 
case, it was evident that they could not be reached by the most 
energetic and vigorous treatment. It was impossible to arouse the 
action of the brain, notwithstanding that there was no inflamma- 
tion, and only that congestion of the blood in the capillaries which 
resulted from the feeble action of the circulatory apparatus, the 
disturbance of the relations of the blood and capillaries, and the 
alterations of the constituents of the blood. 

We do not think that the condition of the spleen in these cases 
was sufficient to cause death, because we have seen cases where 
sudden death occurred from other diseases during convalescence 
from malarial fever, in which the spleen was apparently in a worse 
condition. 

The same remark applies to the alterations of the liver; as far as 
our examination extended, they do not appear to have been suffi- 
cient to cause death. 

The stomach and intestinal canal presented no special patholo- 
gical alterations. The slate-colored spot upon the kidney was 
interesting, especially in its bearing upon a similar change in the 
color of the liver, but it was not sufficient to account for even one 
of the symptoms. 

Can we, then, from this analysis of the pathological phenomena, 
infer that the immediate cause of death did not exist in the patho- 
logical alterations of the organs and tissues, but in the disturbances 
of the general and capillary circulation, and especially of the func- 
tion of the lungs, by the fibrinous coagula in the cavities of the 
heart and in the bloodvessels. 

It is important that lue should^ hefore deciding this question, consider 
the occurrence of these coagula in other diseases^ and the attendant phe- 
nomena. 

Various opinions have prevailed with reference to the fibrous 
concretions found in the heart and bloodvessels after death, and 
almost up to the present time a dispute has been carried on con- 
cerning the time of their formation, some contending that they 
were formed during life, and others that they were formed after 
death. Apart from the evidence afforded by the lamellated struc- 
ture of these bodies, their freedom from colored blood-corpuscles, 
and the absence of colored blood in the surrounding cavities of the 



MALAEIAL FEVEK. 



113 



heart and bloodvessels, we find scattered through the records of 
medicine numerous facts, established by independent observers, 
demonstrating in the clearest manner the formation of these con- 
cretions before death. 

Hewson^ found in the right ventricle of the heart of a dog, which 
had been killed eight hours after receiving a large wound in his 
neck (the wound had during this time inflamed considerably), a 
large whitish polypus, under which was a little blood, still fluid, 
which coagulated after exposure to the air. 

Baillie,^ Morgagni,^ and Albinus^ have described the obliteration 
of veins by the formation of coagula during life. Mr. A. Burns^ 
found in the right auricle of a human heart a large, dense, lamel- 
lated polypus (fibrinous concretion), which was so firmly attached 
to the rough surface of the musculi pectinati as to allow the whole 
mass of the heart, and a considerable portion of the lungs, to be 
suspended by it. Mr. J. Stewart^ has described a heart which con- 
tained fibrinous concretions in the right auricle and in both ven- 
tricles. Mr. Burns reports a case in which a polypus more than 
one inch long was attached so firmly to the septum of the heart 
that the ventricle was torn before the polypus could be torn from 
its attachment. He also affirms that in the centre of this polypus 
an abscess was found which discharged a teaspoonful of perfectly 
formed purulent matter. 

Wardrop^ and CruwelP have recorded similar phenom^ena. 

Graham,^ StenzeV° Meckel, '^ Stoerk,^^and others, have described 
laminated fibrinous coagula in the aorta, and Baillie'^ found two 
coagula, laminated like the walls of the sac of an aneurism, firmly 
attached to the inside of the carotid arteries. 

M. Petit and O'Halloran have observed that the bloodvessels 

' An Experimental Inquiry into tlie Properties of the Blood. By William Hew- 
son. London, 1771. P. 49. 

2 Trans, of A. Soc, vol. i. p. 129. 3 Annot. Academ., lib. 7, c. 2. 

* Epist. 36, art. 10. Op. Path., p. 6, sec. 8. ^ Diseases of the Heart, p. 197. 
6 Edinb. Med. and Surg. Journ., for 1817. 

Baillie's Works, vol. ii. p. 20. A. Burns on the Diseases of the Heart. 
^ De Cordis et Vasorum Osteogenesi in Quatrogenario Observata. Halse, 1765. 
9 Med.-Chir. Transactions, vol. v. p. 297. 
1° Dissertatio de Steatomatibus Aortse. 
" M5m. de I'Acad. R. de Berlin, 1756. 
^2 Med.-Chir. Transactions, vol. v. p. 287. 

'3 Transactions of the Society for the Improvement of Medical and Surgical 
Knowledge, vol. 1. p. 191. 



lU 



OBSEEVATIONS ON 



immediately above, and in sphacelated parts, are filled with fibrous 
concretions. 

Mr. Martial,^ in 1694, in amputating the legs of a poor woman 
affected with gangrene, found that no hemorrhage followed the 
amputation of the first leg, and that in like manner no hemorrhage 
would have followed the amputation of the second leg, had not the 
surgeon, after cutting off the limb, pulled out from the extremity 
of the artery a round, firm, and white clot, about three inches in 
length, which had been pushed a little beyond the cut extremity of 
the artery by the force of the column of blood. 

M. Baron, ^ Yirchow, and Mr. Paget^ first directed the attention 
of pathologists to the frequency and danger of obstructions in the 
pulmonary artery. 

Crampton, Louis, Bougen, Desault, Duncan, and others, have 
recorded cases of the obstruction of the larger bloodvessels by 
fibrinous coagula, and Dr. Eeid,'' Hodgson,^ Andral,^ Tiedemann,^ 
Otto,^ Lobstein,^ Cloquet,^° Carsewell," Langstaff,^^ and others, have 
recorded cases of, and discussed the origin and mode of formation 
of phlebolites. 

Dr. Benjamin Ward Richardson, after the careful examination 
of the condition of the blood after death in 543 cases, occurring in 
man and in the inferior animals, including, in the human subjects, 

' Memoirs of the Royal Academy for the year 1732. 

2 Recherches et Obs. sur la Coagulation du Sang dans I'Artere Pulmonaire et ses 
Effets, Arch. Gen. de Med., sec. iii. t. ii. 

2 Paget on Obs. of Pulmonary Artery, Med.-Chir. Soc. Trans., London, vol. xxvii. 
pp. 162 and 280 ; see also Professor Simpson's Obstetrical Works, vol. ii. p. 34. 

4 Pathological Researches, 1848, p. 395. 

5 Treatise of Diseases of Arteries, p. 521. 
^ Anatomie Pathologique, t. ii. p. 412. 

^ Journal Comp. du Diction, des Sciences Med., t. iii. 

^ Path. Anat. Trans., by South. 

9 Anat. Pathol. 

'0 Path. Chirurgical. 

" Cyclop, of Practical Medicine, art Veins. 

London Medico-Chirurgical Transactions, vol. viii. p. 287. 

'3 " The Fibrinous Constituent in Relation to Disease," by B. W. Richardson, 
Medical Times and Gazette, Feb. 12, 1853. Ranking's Abstract of Med. Sci., June, 
1853, p. 76, Am. ed. " Diagnosis of Fibrinous Concretions in the Heart," by B. W. 
Richardson, Assoc. Med. Journal, April 13, 1855. Ranking's Abstract of Med. Sci., 
June, 1855, No. xxi. p. 73, Am. ed. " The Cause of the Coagulation of the Blood, 
the Astley Cooper Prize Essay for 1856," by Benjamin Ward Richardson, M. D., 
London, 1858. On the Diagnosis of Fibrinous Concretions in the Heart in certain 
cases of Inflammatory Croup," by B. W. Richardson, Med. Times and Gaz., March 
8, 1856. Ranking's Abst. Med. Sci., No. xxiii., Jan. — June, 1856, p. 76, Am. ed. 



MALARIAL FEVER. 



115 



deaths from sudden syncope, epilepsy, apoplexy, enteritis, croup, 
pneumonia, bronchitis, bronchorrhoea, phthisis, mesenteric disease, 
purpura, acute rheumatism, dropsy following scarlet fever, cyanosis, 
hemoptysis, failure of the heart from fatty change, cancer, aneurism 
of the aorta, atheromatous and ossific disease of the aorta, adhesion 
and ossification of the pericardium, simple starvation, cirrhosis, 
degeneration of the heart from drunkenness, hydrocephalus, lateral 
compression of the chest, ulceration and stricture of the oesophagus, 
icterus, general dropsy from mitral disease, dilatation of the right 
side of the heart, senile decay, and hanging — including, in the 
human foetus, deaths in the sixth, seventh, eighth, and ninth months 
of development, and soon after delivery, from various causes, me- 
chanical and morbific — including, in pigs, sheep, oxen, dogs, cats, 
rabbits, guinea-pigs, and birds, deaths from hemorrhage, intestinal 
obstruction, poisoning from narcotic gases, chloroform, ether, smoke 
of puff-ball, carbonic acid, tobacco-smoke, antimooiuretted hydrogen, 
and prussic acid, poisoning by solid opium, salts of ammonia, po- 
tassa, and antimony, strangulation, drowning, electric shock, simple 
exposure to cold, peritoneal dropsy naturally and artificially pro- 
duced, shock from blows on the head, extraction of the kidney, and 
inhalation of oxygen and chloroform, decided that the arguments 
were conclusive for the formation, in certain conditions of the blood, 
and of the circulation and respiration, of fibrinous masses previous 
to death. 

Dr. Richardson, not content with these extensive observations, 
demonstrated, by well-devised and conclusive experiments, that 
fibrinous concretions can be artificially produced in animals during 
life, by the introduction into the blood of those substances which 
disturb the circulation and respiration, and the relations of the 
constituents of the blood to each other, and to the capillaries, and 
to the processes of secretion, nutrition, and excretion. 

The hearts of the living animals were opened, and the fibrinous 
concretions withdrawn whilst the organs were still pulsating.^ 

The Conditions most favorable to the Deposition op Fibrinous 

Concretions. 

The experiments and observations of numerous pathologists and 
physiologists have shown that the leading conditions for the depo- 
sition of fibrinous concretions in the circulatory apparatus during 

' "The Cause of tlie Coagulation of the Blood," pp. 60-140. 



116 



OBSEKVATioxs o:Nr 



life, are actual and relative increase of the fibrin of the blood and 
impeded circulation. 

The positive increase of fibrin^ which occurs in diseases of the acute 
inflammatory class, is frequently attended by a deposition of that 
portion of the fibrin which can be no longer held in solution by the 
blood, and thus cause death. In twenty-three cases of death from 
acute inflammation of the respiratory organs, and which ended 
fatally in the first stages by rapid sinking, Dr. Eichardson^ found 
in every case a fibrinous concretion, which he considered as due, 
in great part, to the excess of fibrin in the blood. 

This observer substantiated this view by a series of experiments 
upon the inhalation of oxygen, which Dr. Gairdner had shown 
would increase the quantity of fibrin in the blood. After con- 
tinuing the inhalation of oxygen for a considerable length of time, 
all the symptoms of fibrinous deposition were produced, and an 
examination of the living heart showed the presence of the con- 
cretion. 

"When the other elements of the blood are diminished, whilst the 
fibrin remains in normal amount, when compared to the previous 
quantities of the constituents and volume of the blood, but rela- 
tively increased to the altered proportions, the fibrin may be de- 
posited. This kind of separation has been observed to occur after 
profuse purging, or after profuse colliquative sweating, and in cases 
of cholera, and in the last stages of phthisis pulmonalis, and in 
anemic conditions of the blood. 

Disturbances in the circulation arising from simple failure of the 
heart, appear to be frequently attended by the deposition of fibrin- 
ous concretions. 

This tendency is marked in all cases of slow death, when the 
action of the heart is enfeebled, and the struggle for life is pro- 
longed, irrespective of the amount of the fibrin, whether increased 
or diminished, as in typhus and malarial fevers, and in purpura, 
and old age, and in debilitated states induced by ardent spirits and 
dissipation, and exposure and privations. 

The deposition of fibrin in the circulation may result from other 
causes far more obscure and difficult of demonstration and investi- 
gation than those just enumerated. Thus, it has been observed 
that these concretions are more common in some seasons than in 
others. This fact would seem to indicate an atmospheric cause, or 



' Log. cit., p. 69. 



MALAKIAL FEVER. 



117 



certain revolutions in the human system, and in diseases. This 
fact shows the impropriety of drawing wide and absolute conclu- 
sions from a single series of investigations on the relative frequency 
of the formation of these bodies in different diseases. 

The presence of certain foreign bodies in the blood may lead to 
the deposition of fibrin, as Gaspard and Lee conclusively demon- 
strated, by the injection of pus into the blood of living animals ; 
whilst, on the other hand, the experiments of Magendie demon- 
strated that the injection of putrefying substances may produce 
the opposite condition — permanent fluidity of the blood. 

Alterations in the constitution of the walls of the capillaries and 
bloodvessels and heart may produce the deposition of fibrin, and 
even the coagulation of the blood, as has been conclusively demon- 
strated by the experiments of Hewson,^ Thackrah,^ Sir Astley 
Cooper,^ and Briicke.'' 

The normal reaction of the blood is alkaline, and it is a well es- 
tablished fact that the alkalies are solvents of fibrin — in fact, the 
theory proposed and ably advocated by Dr. Eichardson,^ ascribes 
the solution of the fibrin in the blood, to the presence of ammonia; 
if, then, the alkalies of the blood be neutralized by an acid gene- 
rated by morbific processes within the blood, or absorbed from 
without, then we would expect the deposition of the fibrin. ISTow, 
in malarial fever, in which these concretions are common, the secre- 
tions of the mouth and the urine are intensely acid. I do not feel 
warranted, however, in propounding this as even a hypothesis, as I 
have found the blood in severe malarial fever alkaline, whilst the 
secretions of the mouth and urine changed the litmus blue to red, 
as rapidly and decidedly as a strong solution of sulphuric acid. 
The degrees of alkalinity of the blood of malarial fever are, how- 
ever, worthy of careful investigation. 

' An Experimental Inquiry into tlie Properties of the Blood, with Remarks on 
some of its Morbid Appearances. William Hewson: London, 1771. Experiments 
xxii. to xxvii., pp. 82-88. 

2 An Inquiry into the Nature and Properties of the Blood in Health and in Dis- 
ease, by Charles Turner Thackrah ; iirst ed,, London, 1819; second ed., London, 
1837, pp. 77-83. 

3 As quoted by Mr. Thackrah in his Inquiry on the Blood, second ed., 1834, pp. 
83-85. 

* An Essay on the Cause of the Coagulation of the Blood, by E. Briicke, M. D., 
British and Foreign Medico-Chirurgical Review, No. xxxvii., January, 1857, p. 141, 
Am. ed. 

_ 5 Cause of the Coagulation of the Blood, pp. 229, 330. 



118 



OBSERVATIONS ON 



Symptoms and Diagnosis of Fibrinous Concretions in the 
Heart and Bloodvessels. 

In order that the connection of these heart-clots with the phe- 
nomena of malarial fever may be placed in the strongest light, we 
will illustrate this branch of our subject, not by our own observa- 
tions, but by those of a far more able and experienced observer and 
experimenter. 

Dr. Benjamin A¥ard Richardson thus describes the symptoms 
and diagnosis of fibrinous concretions in the heart, in his model 
work on the cause of the coagulation of the blood : — 

"The symptoms produced by fibrinous deposition in the heart, 
are strikingly characteristic when they are once understood. But 
as they are commonly superadded to other symptoms, and appear 
at the acme or near the end of a disease, they occasion great per- 
plexity to all who are not prepared to read them off, and whose 
attentions are bent to some more local mischief, by which the dis- 
ease perchance is misnamed, rather than to the grand changes 
which are occurring in the body as a whole. 

"Whatever be the disease, the effects of a fibrinous deposition 
are in the main the same, according to the manner in which the 
deposit itself is laid down. In other words, the symptoms depend 
on the position, form and character of the deposit, less than on 
the pre-existing malady. Whenever fibrinous deposition takes 
place in the heart during the course of a disease, the pure symp- 
toms of the disease are lost or masked by the new symptoms 
which are set up, and which take to themselves a general repre- 
sentative position. 

"The advantages which I have had for tracing out the symptoms 
produced by concretion, and for confirming, by dissection, the diag- 
nosis instituted, have been confined mainly to cases where active 
inflammatory mischief (hyperinosis) has been the forerunning dis- 
order. I write, therefore, from these sources of natural information. 

"All symptoms of acute inflammatory diseases are attended with 
some risk of fibrinous deposition. Taking the majority of such 
cases, the risk is certainly small ; but it is present in each case, and 
what renders the risk more serious is, that such risk or tendency 
to deposition cannot be measured by the local indications of in- 
flammatory mischief in any given case, nor yet by the general 
symptoms which accompany the local. The symptoms of concre- 



MALAEIAL FEVEE. 



119 



tion may intervene in the nnildest, as well as in the severest cases. 
They may creep on insidiously ; they may take effect in a sudden, 
and unexpected outbreak. The following is an outline of a case 
in which the symptoms are unexpected. I write as I have seen, 
and as others have seen. A patient is suffering from an acute in- 
flammatory attack. The local mischief, be it pneumonia, bron- 
chitis, erysipelas, peritonitis, rheumatism, is not in itself such as to 
cause im^mediate alarm. The symptoms go on from visit to visit, 
and the patient is left on one of these occasions, not apparently in 
imminent danger. Unexpectedly there is a sudden call for the 
practitioner. He goes, and in the universal change that has oc- 
curred, he reads off the death signals. The man will sink. The 
fact, as it is written in the patient, is not to be described in words, 
but is easily learned from experience ; it is written in the face of 
the sick man, in the restlessness, in the expression altogether. 
Whoever knows disease, knows at once, without further comment, 
what I mean. It is my business to show how far this finale of in- 
flammatory disorders results from fibrinous deposit, and to indicate 
how the symptoms, when studied in detail, yield the diagnosis of 
concretion. 

" If my observation of the last symptoms, and of the pathology 
of the cases thus referred to, be correct, the origin of the symptoms 
is connected with obstruction on the right side of the heart in the 
majority of instances. The obstruction may be on the left side ; 
but the occurrence is comparatively rare, and the symptoms them- 
selves are modified in detail by the difference in the point of ob- 
struction. Taken generally, the symptoms of fibrinous obstruction 
on the right side are those which might be anticipated, on d priori 
physiological reasoning, as necessarily incident to obstruction of 
blood-making towards the pulmonic circuit. They are the symp- 
toms of arrest in the nutrition and life of the body. They are 
characterized primarily by a peculiar and distressing dyspnoea. 
This occurs, not because the respiration is checked, for the respira- 
tory murmur may be audible enough, but because the current of 
blood to the lungs is in part cut off. As an addendum^ emphysema 
of the lungs, especially in children, results; and the physical signs 
of this lesion are often a valuable corroboration of the presence of 
concretion of the right side. The dyspnoea depends on the deficiency 
in the supply of blood to the lungs and the nervous centres. The left 
side of the heart being imperfectly supplied with blood, the arterial cir- 
culation is weakened; the pulse is small and intermittent ; the surface 



120 



OBSEEVATIONS ON 



of the lody is cold, and generally ivhite as marhle ; hut, as there is 
stagnation of blood in the venous circuit, the more vascular imrts, as 
the lips and centre of the cheeks, are often of a leaden hue. There is 
general muscular jjrostration ; and, as the brain is not supplied normally 
with blood, the muscles are not under the control of the will, but are in 
a continued restless motion. The mind loses its power ; the acts of 
excretion are performed involuntarily ; and death sets in, the gasping 
respiration outliving the paralyzed and obstructed heart. 

"The symptoms thus portrayed are applicable to cases in which 
they last for several hours ; in such examples the concretion is 
either lodged in the right auricle, or is being laid down as a tube 
in the infundibulum and pulmonary artery, or is commencing at 
the extremities of the pulmonary circulation. But other cases 
occur, where the course of the symptoms is suddenly cut short. 
There may have been some slight premonitory symptoms, but the 
suddenness of the end is the great fact. The patient, previously 
exhausted, is rising in bed, or m.aking some muscular movement or 
strain, when suddenly he reclines or falls, breathless, faint, feebly 
convulsed, dead. I have met with, two illustrations of this last 
event. The cause in both cases was the same, and the cause is 
ordinarily the same; the pulmonary artery is suddenly blocked 
up with a fibrin cylinder. In each of these cases, observed by 
myself, this cylinder has been hollow, and had conveyed a stream 
of blood like a tube. Its base had commenced in the infundibu- 
lum ; its apex had ascended into the pulmonary artery. The con- 
cretion had been suddenly torn from its attachments, and carried 
up into the artery. In its centre was a column of red clotted 
blood ; externally it was encased in a thin layer of blood, the 
result of a rush of blood past the concretion after its detachment. 

"Once more, there are instances where the symptoms are unusu- 
ally prolonged. In one instance which I observed, the symptoms 
of dyspnoea extended over many days, and anasarca supervened as 
a result of the obstruction. The concretion in this instance com- 
menced in the auricula, where it had a firm attachment, and sent a 
prolongation downwards into the ventricle. In the case supplied by 
Dr. Sayer the symptoms of dyspnoea extended over many months; 
and Mr. H. Lee has recorded an instance in which a similar exten- 
sion of symptoms occurred. 

" When the concretion is deposited on the left side of the heart, 
the ventricle, the infundibulum, and the ascending portion of the 
aorta are the most common positions. The symptoms which cha- 



MALAKIAL FEVER. 



121 



racterize the presence of concretion here situated are different in 
many respects from the preceding. There is a tumultuous action 
of the heart, a symptom which is strikingly indicative that the 
deposit is on the left side. There is congestion of the lungs and suffo- 
cative dyspnoea^ icith exp)ectoratioh^ sometimes mixed with hJood. The 
surface of the body is of a leaden color^ and the hody is cold. The 
muscular perturbation lap)ses into poioerful convulsions^ and coma pre- 
cedes dissolution. These symptoms may extend over may hours. 

" But, as in the preceding class of cases, the symptoms may also 
occur in a sudden manner. The patient, in moving or making a 
straining effort, suddenly falls back, is seized with a violent con- 
vulsive fit, and so expires. I once saw these symptoms and this 
sudden form of death in an old lady, who had previously suffered 
from no other symptoms than a slight attack of cold. In rising 
from bed, she fell, as I have described, and died before medical 
assistance could be obtained. In this case the concretion had 
formed as a hollow cylinder in the infundibulum of the left ven- 
tricle, had become dislodged, and had been carried into the aorta, 
which it entirely occluded. 

"Again, the symptoms of the concretion may extend over a long 
period. The concretion may, as I have shown, become organized. 
In such case the symptoms are those of valvular obstruction on 
the left side. Such cases often end suddenly at last. Cases may 
be met with in which concretions exist on both sides of the heart 
at the same time. In such instances, unless the concretion on the 
right side be small, or placed out of the direct course of the circu- 
lation, the symptoms partake of the characters which belong to 
deposition in the right cavities. 

" The pre-existence of disease of the heart, either acute or chronic, 
favors materially the deposition of fibrin. We have seen in acute 
endocarditis how this obtains. It is easy to see, and cases abundant 
are on record for illustration, to what extent dilatation of the heart, 
feebleness of its walls, or induration of its valves, favors the forma- 
tion of concretion. 

" I have often been asked whether there are no reliable physical 
diagnostic signs of concretion. I think not. There are sometimes 
abnormal sounds, but it is difficult to distinguish these from mur- 
murs, the results of valvular lesion. The tumultuous action of 
the heart, taken with the general symptoms, is always a valuable 
diagnostic mark of concretion of the left side; but this is com- 
patible with other diseased conditions. The weak, irregular action 
9 



122 



OBSEEYATIONS ON 



is, with the general symptoms, always a valuable diagnostic sign 
in concretion of the right side ; but it is equally compatible with 
other causes. In some cases, where the concretion interferes with 
the action of either the auriculo-ventricular or semilunar valves, 
there is a muffled character with the sounds, dependent on the 
obstacle to the play of the valves by the tension of which the 
sound is produced. But as it is scarcely ever the fact that both 
sets of auriculo-ventricular valves, or both sets of semilunars, are 
affected simultaneously by concretion, loss of either sound is of 
rare occurrence. In short, the only physical signs of moment are, 
feebleness of action, tumultuous action, or occasionally a peculiar 
rumbling, fidgety, jog-trot motion, with which the two sounds are 
heard in natural sequence as regards each other, but irregularly 
and lispingly. The diagnosis must therefore rest 2ipon the general 
symptoms, rather than on the physical. The nature of the case must 
be considered. All acute sthenic inflammations form favorable 
pre-existing conditions; pneumonia foremost of all. The puerperal 
state is second to none in this particular, and the symptoms of 
concretion are often as insidious as they are sudden. I do not 
speak here of puerperal phlebitis, and of deposits in the veins, but 
of cases where there has been no outward sign, either during preg- 
nancy or after parturition, and where the woman suddenly suc- 
cumbs, without any preliminary indication of acute disease. In 
these instances, unattended with pre-existing changes in the venous 
trunks, or evidence of inflammatory lesion, we can only, in the 
present state of our knowledge, assign as a cause of the deposition 
excess of fibrin in the blood, arising from absorption of the thick- 
ened uterine walls, or suppressed lacteal secretion, or neutrality or 
deficiency of the fibrin solvent. I have more than once seen a 
sharp inflammatory attack, without direct evidence of organic in- 
flammation, end fatally by the deposition of concretion. Many 
cases of so-called " simple inflammatory," or perhaps continued 
fever," are of this character. After death it is found that there 
has been an inflammatory afiection of some organ, but that such 
afi'ection has not been diagnosed. In these examples the spleen is 
often the organ which has suffered the local lesion, but the symp- 
toms have not been sufficient to be readily detected during life. 

"By some observers, who admit that the fibrinous deposit may 
be formed before death, an argument is sometimes used that such 
concretions are always formed in the last hours of existence, and 
that they are rather the sequences of the dying state than its 



MALAKTAL FEVER. 



123 



precursors and final cause. To some extent this argument has 
weight; for there are cases certainly in which these concretions 
are found, where the inference is fair that death would have occur- 
red though the concretion had not existed. On the other side, 
various instances have been given, where both the symptoms and 
the pathology show that the concretion was the inevitable cause of 
dissolution. In other words, the patient would not have died if 
the concretion had not been formed. Moreover, in all cases where 
the deposit occurs this is clear, that in the majority of cases it is 
the final seal and bond to the death claim. 

" The question may be asked. Of what good is this knowledge 
concerning concretions in the heart? Why be anxious to learn 
the existence of a cause of death, which, by its irremediability, may 
be considered death itself? I answer, great good. I am not with- 
out hope that the day may come when science shall show us how 
the dissolution of these concretions may in some cases be effected; 
for I have seen them partly dissolved as an effect of alkaline treat- 
ment. 

"But irrespective of this matter, the correct diagnosis of concre- 
tion is a guide to prognosis, and is a guide against many forms of 
meddlesome and mischievous, because useless, practice. Take two 
examples: In the latter stages of inflammations, bleeding is noto- 
riously bad practice. The reason is obvious ; and I regret to say 
I have seen the evil too obviously and practically explained. In 
these cases, the tendency of the disease is towards fibrinous depo- 
sition ; and the tendency of hemorrhage is towards the same event. 
Therefore, as the practitioner bleeds, the balance of the blood-con- 
stituents, already disturbed, is disturbed the more; all that was 
wanting to secure deposition is secured; the circulation is enfeebled, 
and the proportion of water and fibrin is increased. The deposit 
forms, and the patient sinks. In one instance of pneumonia I saw 
the fatal symptoms of concretion on the right side follow the free 
abstraction of blood, as clearly as the symptoms of narcotism can 
ever be observed to succeed upon the administration of an opiate. 
For the same reason, in the latter stages of acute inflammatory 
affections, it is equally dangerous to carry the depressing system 
by medicines to an extreme, or to produce too free an elimination 
from the body; of all medicines, in such stages, purgatives and 
opiates should be alike avoided. Lastly, the correct diagnosis of 
concretion in the heart may prevent unnecessary surgical interference, 
and explain the reason why some measures, conducted on the most 



124 



OBSEEVATIOXS ON 



scientific surgical principles, miss their intended object. This is 
strikingly illustrated in the disease, true inflammatory croup. In 
this affection, as I have proved by repeated inspections, concretions 
definitely formed from blood in motion, and long before death, are 
often found in the heart after death has occurred. Further, I have 
been able in this disease to trace the symptoms of concretion as 
clearly as I had previously traced the special, local, or inflamma- 
tory symptoms of the disorder. Thus, in croup there may be death 
from one of two sources: from the obstruction in the larynx — 
asphyxia; from the obstruction in the heart — syncope; or from the 
combination of these. If, then, the symptoms are clearly those of 
pure asphyxia, dependent obviously on the obstruction in the air- 
passages, the operation of tracheotomy is the grand remedy. But 
if the stethoscope tells that the air enters the lungs with moderate 
freedom at each inspiration ; if indications of emphysema are pre- 
sent ; if the symptoms are those of obstruction at the heart — syn- 
cope — then is the operation of tracheotomy as useless as would be 
that of phlebotomy for removing a solid plug from the windpipe."^ 
A careful comparison develops a close resemblance between the 
symptoms of concretions of fibrin in the heart and bloodvessels, 
and many of the symptoms of the cases of congestive malarial fever 
now recorded. 

In view of the rapid, feeble, intermittent pulse ; disturbed, full, 
panting respiration; rapid, feeble, fluttering action of the heart; 
cold extremities, exhaustion of the muscular forces, stupor, wan- 
dering of the intellect, inability to control the muscles, and acts of 
excretion ; in view of the sudden onset of all these symptoms in 
malarial fever ; in view of the size and structure of the coaafula 
found in the heart and bloodvessels after death, in the cases pre- 
senting these symptoms ; in view of the close correspondence of 
these symptoms with those characteristic of the deposition of fibrin 
in the heart and bloodvessels ; in view of the observations and 
experiments of Baillie,- Morgagni,^ Albinus,^ Burns,^ Hewson,^ 
Gould, Templeman, Haller, Stewart,' Graham,^ Chisholm,^ Ward- 

1 Cause of the Coagulation of tlie Blood, pp. 423-434. Tlie Italics are our own. 

2 Trans, of A. Soc, vol. i. ^ Annot. Academ., lib. rii. c. '1. 
4 Epist. 36, art. 10. ° Diseases of the Heart. 

6 An Experimental Inquiry into the Properties of the Blood, 1771. 

' Ed. Med. and Surg. Journal for 1817. 

s Med.-Chirurg. Transactions, rol. v. p. 297. 

s An Epidemic Polypus in G-ranada in 1790. 



MALAEIAL FEVER. 



125 



rop,^ Cruwell,^ Stenzel,^ Petit, MartiaV Baron,^ Yircliow,^ Bouil- 
laud/ Meigs,^ Davy,^ Fuller, SimoD,i° Simpson,ii Paget,!^ Crisp," 
Kirkes,^^ Wagner,^^ Pokitansky,^^ Picbardson,^^ and others, we are 
justified in asserting that the fibrinous element of the blood may 
be deposited in the heart and bloodvessels during life in malarial 
fever, and not only give rise to a distinct set of phenomena, but 
cause death in cases which otherwise would not have terminated 
fatally. 

The evil effects of the deposition of fibrin in the bloodvessels are 
by no means confined to the period attending and immediately suc- 
ceeding their formation. These fibrinous bodies, wherever formed, 
and whatever be their situation, are full of peril, and may remain 
so long after the circumstances which gave rise to them have passed 
away. The observations of Dr. Wm. Senhouse Kirkes^^ have de- 
monstrated that the large masses may at any time be detached from 
the points to which they were originally attached (the valves of the 
heart and bloodvessels, or the carne^e columnse, or chordae tendi- 

1 Baillie's Works, vol. ii. p. 20. 

2 De Cordis et Vasorum Osteogeneses in Quatrogenario Observata ; Halje, 1767. 
^ Dissertationes de Steatomatibus Aortse. 

* Memoirs of the Royal Academy for the year 1732. 

5 Recherches et Obs. sur la Coagulation du Sang dans I'Artere Pulmonaire, et ses 
Effets ; Arch. Gen. de Med., sec. 14, t. ii. 

^ On Plug Formations and Obstructions in the Bloodvessels ; Handbuch der Spe- 
ciallen Pathologie und Therapie ; Erlangen, 1854, Erstes Bande. 

^ Traite Clinique des Malades da Coeur, Apendice, tome ii., Paris, 1835. 

8 Philadelphia Medical Examiner, No. 51, 1849. 

9 Physiological and Anatomical Researches, London, 1839. 

10 Animal Chemistry, 1843, " Obstetrical Works. 

1^ On Obstructions of the Branches of the Pulmonary Artery, Med.-Chir. Trans., 
vol. xxvi., 1844. 

13 On the Structure, Diseases, and Injuries of the Bloodvessels, 1847. 

1* On some of the Principal Effects resulting from Detachment of Fibrinous 
Deposits from the Interior of the Heart, and their Mixture with the Circulating 
Fluid, Lancet, June 5, 1852 ; Ranking's Abstract, 1852. 

1^ Elements of Physiology. i^ Manual of Pathological Anatomy. 

1^ Cause of the Coagulation of the Blood, 1858. The Fibrinous Constituents of 
the Blood in relation to Disease, Medical Times and Grazette, Feb. 12, 1853. Diag- 
nosis of Fibrinous Concretions in the Heart, Assoc. Med. Journal, April 13, 1855. 
See also Turner, Thackrah on the Blood, 1819. An Essay on the Cause of the 
Coagulation of the Blood, by E. Briicke, British and Foreign Medico-Chirurgical 
Review, No. xxxvi., Jan., 1857, p. 141, Am. ed. 

1^ On some of the Principal Effects resulting from Detachment of Fibrinous 
Deposits - from the Interior of the Heart, and their Mixture with the Circulating 
Fluid, London Lancet, June 5, 1852. 



126 



OBSEEYATIONS ON" 



nedd of the heart), and conveyed with the circulating blood until 
arrested within some arterial channel, which might thus become 
completely plugged up, and the supply of blood to an important 
part be suddenly cut off, from which serious if not fatal results 
would ensue ; or smaller masses might be detached, and pass on 
into arteries of much less size, or even into the capillaries, and pro- 
duce stagnation and coagulation of the blood, and all the attendant 
changes and phenomena; or the masses of fibrin may soften, break 
up, and discharge the finely granular material resulting from their 
disintegration into the circulating blood, and contaminating the 
fluid, might excite symptoms very similar to those observed in 
phlebitis, typhus, and other analogous blood-diseases. The parts 
of the vascular system to which these detached masses of fibrin 
would be transmitted, will depend upon the parts of the circulatory 
system from which they are detached ; thus, if detached from the 
left heart, they would pass into the aorta and its branches, and 
produce various disturbances in the nutrition, secretion, and func- 
tions of the organs; and if detached from the right heart, the lungs 
would become the primary, if not the exclusive, seat of their ulti- 
mate deposition. 

We will hereafter record cases presenting certain symptoms, 
which might be referred to the detachment of these fibrinous con- 
cretions, and their subsequent lodgment in different organs. 

In affirming that death may be, and is often produced in mala- 
rial fever by the deposition of fibrinous concretions, we do not for 
one moment lose sight of the fact that the great questions after all 
to be settled are: What produced this state of things, favorable to 
the formation of these concretions ? What are the chemical and 
physical changes of the blood and of the bloodvessels ? What are 
the causes of the disturbance of the action of the heart and capil- 
lary circulation, which precede and determine the deposition of the 
fibrin of the blood ? 

The correct answer of these questions involves the complete 
knowledge of the physical and chemical relations of fibrin to the 
elements of the blood, and to the bloodvessels and surrounding 
tissues; involves the complete knowledge of the origin and offices 
of fibrin in physiological and pathological conditions ; involves a 
knowledge of the physical, chemical, physiological, and patholo- 
gical relations of morbific agents, not only to the fibrin, but to all 
the constituents of the blood, and to the containing vessels, and to 
the organs, and tissues, and apparatus. The impossibility of answer- 



MALARIAL FEVER. 



127 



ing these important questions is immediately seen, when we review 
the whole controversy concerning the cause of the coagulation of 
the blood, the knowledge of which should form the starting-point 
in the attempt to solve these difficulties. 

We are actuated by no disparaging or captious spirit when we 
assert that, notwithstanding the laborious investigations of Hewson, 
Thackrah, Eichardson, and Briicke, we have no theory which will 
explain satisfactorily and thoroughly the coagulation of the blood 
under all circumstances ; when we assert that the theories thus far 
proposed are expressions rather of necessary and attending circum- 
stances for the manifestation of the phenomena of coagulation, than 
of the true causes ; when we assert that notwithstanding the obser- 
vations and reasonings of Mulder, Paget, Simon, Carpenter, Yir- 
chow, Briicke, and others, the origin, offices, and ultimate changes 
of fibrin are still matters of dispute, and are questions to be deter- 
mined by future observation and experiment. 

If we adopt the hypothesis of Dr. Eichardson, that the fibrin of 
the blood is held in solution by ammonia, and that the coagulation 
of the fibrin is due to the escape of the ammonia, the most import- 
ant questions, in a physiological, as well as in a pathological point 
of view, with reference to the true causes of the coagulation of the 
blood, remain unsettled. 

It has not as yet been determined what are the physical and 
chemical properties upon which these relations of fibrin and am- 
monia are dependent ; the origin and variations in quantity of the 
ammonia in different physiological and pathological states, and its 
relations to the other constituents of the blood, have been only 
barely indicated, and not determined ; and no hypothesis yet pro- 
pounded explains the phenomenon of the more rapid coagulation of 
blood in a dead than in a living heart or bloodvessel ; and no series 
of experiments have yet settled definitely and absolutely the ques- 
tion, whether fibrin exists as fibrin in the blood, or is formed by a 
chemical change at the time of coagulation. 

If we adopt the hypothesis that fibrin is held in solution in the 
living body by nervous and vital influences, and that its coagula- 
tion is due to the abstraction of nervous and vital infi.uence, the 
questions immediately arise. What are nervous and vital influences? 
How are they produced? What are their relations to fibrin? 

If we adopt the hypothesis of Dr. Eichardson, that the primary 
and essential part of the process of coagulation consists in the evo- 
lution of a volatile principle, and that the volatile principle thus 



128 



OBSEEVATIONS ON" 



eliminated from blood, is ammonia, the questions immediately 
arise: Does this ammonia which holds the fibrin in solution, de- 
crease in the latter stages of malarial fever, and in the latter stages 
of all those diseases in which fibrinous concretions are formed be- 
fore death ? What are the causes of the decrease of ammonia? What 
are the disturbances in the chemical changes of the living organ- 
ism, which lead to this decrease of ammonia ? 

If we adopt the hypothesis, supported by the experiments of 
Hewson, Thackrah, Cooper, Briicke, and others, that the solution 
of fibrin in the living body is dependent upon its relations with 
the walls of the containing heart and bloodvessels, the main ques- 
tion to be settled is, What are these relations, and upon what are 
they dependent, and how may they be disturbed? 

If we adopt the hypothesis so ably advocated by Briicke, that 
the fibrin exists not as fibrin, but as a soluble albuminate, and is 
formed at the moment of coagulation, at the expense of a portion 
of the albumen of the blood, by a change in its atomic constitu- 
tion, and that these changes are prevented during life by an influ- 
ence exerted by the coats of the living bloodvessels: the cause and 
character of these chemical changes of the albumen, and the cause 
and character of the influence of the coats of the living blood- 
vessels upon the blood, are still unknown. 

If, with Zimmerman, we think that the coagulation of fibrin is 
nearly allied to the process of fermentation, which may be regarded 
in the light of an oxidizing process, and is brought about by a 
kind of putrefaction occurring in some of the constituents of the 
blood, after its removal from the body, the questions are still un- 
answered : What is this oxidizing process ? Why does it not take 
place in the circulating blood, which is not deficient in oxygen ? 
What is this peculiar kind of putrefaction, and what previous 
chemical changes does it involve ? What is the nature of the putre- 
factive process which leads to the deposition of fibrin in the living 
heart and bloodvessels in malarial fever, and other diseases ? 

If we combine the truths of all the hypotheses of the coagulation 
of the blood thus far propounded, we will have the same number 
of important questions to be determined. 

If we say that the formation of fibrinous concretions in malarial 
fever is due to impeded circulation; while we express a valuable 
fact, leading to the development of important principles of treat- 
ment, we do not, by any means, explain the phenomena of the 
deposition of fibrin, but only state one of the favorable circum- 



MALAEIAL FEVER. 



129 



stances, and besides the important questions which we have pro- 
pounded with reference to every hypothesis of coagulation, thus 
far advanced, the question still remains : What produced the retard- 
ation of the circulation ? If the retardation of the circulation was 
due to the effects of the malarial poison, what are those effects ? 
where, when, and how did the poison act? Did the poison act 
alone upon the structures of the circulatory apparatus? or did 
the poison act primarily upon the blood, and through the altered 
constituents of the blood upon the nutrition and development of 
the forces of the circulatory apparatus ? or did the poison in the 
altered products of the blood act upon one or both the nervous 
systems, and through them produce such irregularity and feeble- 
ness in the circulatory apparatus, as led to the deposit of fibrinous 
concretions. 

Notwithstanding that the facts now recorded are not sufficiently 
numerous, to warrant the assertion that fibrinous concretions are 
formed previous to death, in every case of malarial fever ; not- 
withstanding that the causes of the formation of these clots are ob- 
scure, complicated, and unknown; notwithstanding that the causes of 
death may not be connected with those which lead to the deposition 
of fibrin in the living vessels ; we may, nevertheless, assert that the 
knowledge that these concretions may and do form in many cases 
of malarial fever, and produce a fatal termination in cases which 
would not otherwise have thus terminated, is of the utmost value 
to practitioners of medicine in the South and Southwest, where the 
severest grades of malarial fever prevail. 

Principles of Treatment best adapted to prevent the Formation 
or Fibrinous Concretions in the Heart and Bloodvessels. 

When the pulse is rapid and feeble, beating from 120 to 160 
times in a minute, and feeling like the vibrations of a delicate sil- 
ver thread ;' when the heart thumps, feebly, and spasmodically, and 
rapidly against the walls of the thorax ; when the respiration is 
full, panting, labored, varying from 30 to 50 in the minute ; when 
the skin is hot, and parched, and rough, or bathed in a cold clammy 
sweat; when the temperature of the extremities is far below that of 
the trunk, which by no means corresponds with the increased efforts 
at the introduction of oxygen ; when the circulation of the blood 
in the capillaries of the extremities is almost entirely checked ; 
when the chemical changes of the solids and fluids are in a great 
measure arrested, and perverted, and the development of the nerv- 



130 



OBSEEVATIONS ON 



ous and physical forces arrested, and their correlation disturbed ; 
when the altered blood stagnates in the capillaries of the brain, 
and the intellect is either abnormally excited or depressed ; when 
the altered blood stagnates in the capillaries of the tongue and sto- 
mach, and the brilliant red, dry, rough tongue, is but a fit index 
of the consuming thirst of the restless patient tossing from side to 
side, and pleading for a drop of water ; we have all the disturb- 
ances necessary for the formation of fibrinous concretions, and the 
treatment must be energetic and prompt. 

Ihe toT]pid nervous centres must he aroused ; the feehle general and 
capillary circulations must he aroused ; oxygen must he rapidly intro- 
duced^ and correspondingly rapidly distrihuted through all parts of the 
system; the chemical changes hy ivhicJi the muscular and nervous forces 
and heat are developed and maintained, must he excited and maintained 
with energy, hy the rapid distribution of the elements of chemical change ; 
the products resulting from these chemical changes, and from the changes 
induced in the constituents of the hlood and organs, hy the malarial poi- 
son, must he removed. 

Those remedies should he employed, ivhich excite the general and ca- 
pillary circulation ; promote the introduction and distribution of oxy- 
gen ; increase the chemical changes, and excite the development of the 
muscular and nervous forces. 

Sulphate of Quinia and diffusible stimulants. Brandy and Carbon- 
ate of Ammonia, should be freely and promptly administered, and 
sinapisms freely applied. 

Bottles of hot water, or better still, the hot bath, should be used 
to impart heat, and stimulate the capillary circulation, and relieve 
the engorgement of the large organs. 

Brandy and Ked Pepper may be applied to the surface with ad- 
vantage. 

The Sulphate of Quinia may be administered to adults in doses 
of 5 to 30 grains, every one, two, or three hours, according to the 
urgency of the symptoms, up to from 30 to 80 grains during the 
twenty-four hours. The best method of administering the Sul- 
phate of Quinia, is dissolved in a weak solution of citric or acetic 
acids, or in lemon-juice. It is much more readily and rapidly ab- 
sorbed, in the soluble form. If the stomach rejects the Sulphate of 
Quinia, it should be administered in solution with starch, by the 
rectum. 

Every practitioner of medicine in the Southern and Southwestern 
districts of the United States who has employed the Sulphate of 



MALAKIAL FEVEK. 



131 



Quinia in large doses, is aware of the surprising rapidity with 
which, in many cases, the most alarming symptoms of congestive 
fever will be dissipated by the action of sulphate of quinia in large 
doses. The patient will frequently be snatched from the very jaws 
of death, and be blessed with a recovery as rapid as his attack. In 
sucb cases, we must conclude that the action of Sulphate of Quinia 
alone is able to prevent the formation of fibrinous concretions. 

The Sulphate of Quinia prevents the deposition of fibrin in the 
blood, by its direct action upon the sympathetic and cerebro-spinal 
nervous systems, or by its excitement of the general and capillary 
circulations, either directly, or through the nervous system, or by 
its relations to the chemical changes of the elements of the blood 
and malarial poison, or by its action in all these modes combined. 

Diffusible stimulants should be administered because they act 
more rapidly in exciting the nervous systems and in arousing the 
circulation, than the sulphate of quinia. 

If the formation of fibrinous bodies in the heart and bloodvessels 
be common in malarial fever, and if the statement of Dr. Benjamin 
Ward Eichardson, of London, that the fibrin is held in solution in 
the liquor sanguinis of the living bloodvessels by Ammonia be true, 
and if, as we shall hereafter demonstrate by numerous facts and cases, 
the action of the malarial poison is depressing, and not inflammatory, 
then Carbonate of Ammonia should be administered freely in mala- 
rial fever. It should be administered freely in congestive fever 
when there is a feeble, rapid action of the heart, and diminished, 
aberrated forces, because it excites the general and capillary circu- 
lation ; excites the chemical changes in the capillaries, necessary 
for the development of the muscular and nervous forces ; arouses 
the sympathetic and cerebro-spinal nervous systems; promotes 
secretion and excretion; and furnishes the volatile alkali to the 
blood, which holds the fibrin in solution. 

We do not for one moment advocate the Carbonate of Ammonia 
as a substitute for Sulphate of Quinia. The Carbonate of Ammonia 
does not cure the disease. The Carbonate of Ammonia merely 
arouses the system, prevents a distressing and fatal accident, and 
prolongs life until the Sulphate of Quinia can act. Stimulants and 
sinapisms also arouse the nervous system and circulation, and lead 
to an increased supply and distribution of the great element of 
chemical change (oxygen), and thus furnish the conditions of an 
increased development of the physical, chemical, muscular, and 
nervous forces ; but they cannot cure the disease, they cannot di- 



132 



OBSEEVATIONS ON 



rectly remove, or chemically alter, or destroy the poison ; they 
cannot, then, take the place of the Sulphate of Quinia. 

To prevent the formation of fibrinous concretions in malarial 
fever, we must administer the Sulphate of Quinia in full doses, in 
conjunction with the Carbonate pf Ammonia, stimulants, and the 
free use of sinapisms and the hot bath. 

This course of treatment may be instituted regardless of the dry, red 
tongue, tender epigastrium, and wandering and torpid intellect, and 
distracting pains in the head. I have observed in numerous cases, 
that under the free use of stimulants, sinapisms, and large doses of 
the Sulphate of Quinia, the dry, harsh, hard, red, glazed tongue be 
came moist, soft, and pale ; the pulse diminished in frequency, and 
increased in fulness ; the dry, harsh skin rendered moist ; the cold 
clammy skin restored to its normal state; the relations between 
the circulation in the trunk and extremities restored; the correla- 
tion between the physical, chemical, vital and nervous forces re- 
stored; and the wild delirium succeeded by calm intelligence. 
Whilst on the other hand, in more cases than one, I have seen 
active purgation, and the administration of alterative doses of Calo- 
mel, convert cases of ordinary intermittent and remittent fever into 
the dangerous congestive type, resulting in the formation of heart 
clots and speedy death. When stimulants and Sulphate of Quinia 
have been withheld, I have seen the patient die from complete ex- 
haustion of the nervous and vital powers consequent upon the 
action of the malarial poison, either directly upon the nervous 
ganglia of the sympathetic system, presiding over the circulation 
and respiration, or by disturbances of the relations existing be- 
tween the sympathetic and cerebro-spinal nervous systems ; or pri- 
marily upon the cerebro-spinal system and sympathetic system 
simultaneously; or by such changes in the elements of the blood 
(especially of the blood-corpuscles), as resulted in the perversion of 
the nutrition of the nervous ganglia; or by the generation of com- 
pounds in the blood, and in the secretions of the liver, spleen and 
alimentary canal, which acted as poisons upon the sympathetic and 
cerebro-spinal nervous systems; or by the sim.ultaneous action of 
the poison in all these different modes. 



MALAEIAL FEVEK. 



133 



Physical and Chemical Changes of the Constituents of the 
Blood in Malarial Fever. 

The method of analysis^ employed in these investigations is simi- 
lar in many respects to that employed by MM. Becquerel and 
Rodier, Bowman, and others. 

In the present state of physiological and pathological chemistry, 
objections may be alleged against every method of analyzing the 
blood, thus far proposed. 

All physiological chemists have failed to ascertain with absolute ac- 
curacy the amount of solid matter in the serum of 1000 parts of blood ; 
and there is no method by which the colored blood-corpuscles can 
be separated from the surrounding liquor sanguinis, and the che- 
mical constitution and relative proportions determined with abso- 
lute accuracy. It is evident, therefore, that when we attempt to 
calculate the moist blood-corpuscles by the formula of C. Schmidt, 
whatever error entered into the calculation of the solid matters of 
the moist blood-corpuscles, will be increased fourfold, whilst the 
error in the calculation of the constituents of the liquor sanguinis 
will increase, not only in a direct ratio to the errors in the calcula- 
tion of the blood-corpuscles and solid matters of the serum of 1000 
parts of blood, but also in a definite ratio to the actual increase or 
decrease of the moist blood-corpuscles. That error exists in this 
method of analysis, is rendered evident when we calculate the con- 
stituents of 1000 parts of liquor sanguinis from the data obtained 
by subtracting the moist blood-corpuscles from 1000 parts of blood, 
and considering the remainder liquor sanguinis. The results thus 
obtained, do not correspond with those obtained from actual analy- 
sis of 1000 parts of liquor sanguinis. To render this error evident, 

' Pathological Cliemistiy, hj MM. Becqnerel and Rodier. Translated by S. T. 
Speer, M. D. London, 1857, p. 19 et seq. Bowman's Medical Chemistry, pp. 145- 
194. Philadelphia, 1850. Simon's Chemistry of Man, p. 142. Philadelphia, 184G 
Lehmann's Physiological Chemistry. Trans, by G. E. Day. Cavendish Society pubs., 
vol. ii. pp. 153-280. London, 1851-1854. See also American ed., edited by Prof. 
Rogers, vol. i. pp. 541-648. Manual of Blood and Urine, by Griffith, Reese, and 
Markwick. Philadelphia, 1848. Physical, Chemical, and Physiological Investiga- 
tions upon the Vital Phenomena, Structure, and Offices of the Solids and Fluids 
of Animals, by .Joseph Jones (American Journal of Medical Sciences, July, 1856, p. 
46). InvestigatitDns, Chemical and Physiological, relative to certain American Ver- 
tebrata, by Joseph Jones. Smithsonian Contributions to Knowledge, 1856. An- 
leitung zur Qualitativen -und Quantitativen Zoochemischen Analyse, von E. von 
G-oriip Besanez. Nurnberg, 1854. 



13i 



OBSERYATIOXS ON 



I have in the succeeding analyses, stated the actual analysis of 1000 
parts of liquor sanguinis, and that calculated from the constitution 
of the liquor sanguinis determined in 1000 parts of blood, by the 
subtraction of the moist blood-corpuscles. The former, by actual 
experiment, is always marked (1); the latter, by calculation, is 
always marked (2). 

A perfect method of analyzing the blood will never be obtained, 
until it be possible to obtain the moist, colored, and colorless blood- 
corpuscles entirely free from the intercellular fluid, and without the 
loss of any of their constituents, or the introduction of any foreign 
bodies. As yet the method first applied by Figuier, and improved 
by Dumas and Hdfe, the method of F. Simon, and the method of 
direct measurement and enumei'ation of the blood-corpuscles in a 
definite portion of blood, and, in fact, every method thus far pro- 
posed, is imperfect, and they have one and all failed to yield abso- 
lutely accurate results. 

"Whilst these failures should lead to caution, and the extension 
of experiments and investigations, they should by no means lead 
to the entire distrust and abandonment and condemnation of these 
observations ; they should lead to an appreciation of the difficulties 
of the investigation, and of the exceeding complexity of the fluid 
substances to be examined ; they should lead to an appreciation of 
the causes of the differences in the results obtained by diiferent 
observers. When those parasites and vultures of the medical pro- 
fession who make their living, in a great measure, by rehashing 
old objections, original neither with themselves nor their race, shall 
enter laboratories in sickly countries, reeking with the fumes of 
urine, blood, and brains, and demonstrate by actual experiment, the 
truth of their objections, and the feasibility of their plans of reform 
and improved investigation, they will be in a position at least to 
criticize, if not to propose something better. The following table 
will illustrate the changes of the blood in malarial fever : — 



MALAEIAL FEVEE. 



135 



-H a? o5 1 

^ t- QCl 

(TS d 'O 

CO r-. I !>. 

CO Ol 05 00 



CO ao c» (M cx) 



r- (M O O 'O O) -f CO 
CO CO O 'C- »S CO >o 



CO 05 CO 
^ IC -H 
CD <N CO 
(N id rH 



:o CD 

CO CO 
CO ^ 

c o 



r-l O O CO 
r-^ O --O C<I 
IC 05 o 
CD CO !>j 
-H r-H CO 
OO OS C3 CO 



05 O CO 1 

cc 1.0 1^ ! 
o c; (M p 



t^C<lO-}J!MC<lr~C0co 

t-' CO CD CO (m' !M CO d 
1-1 CO C- CO O 
CO C<< CD CO 



I T— I Cj; 

I 05 :D 00 (M 
I (M r-H 1-1 (M 



OCOO-t<Ir^CDr-iOO 

ocoo>ooo-Hcor-co 
ino-^t^coOi— it^t-^ 
i>Tt<»ocdcDi-ic<ieoco 

Tt< TfH O r-l 



> (M O O -H -H 1 



O O -f O n-( 



05lMC0C0Or^C0C0<M 
O CO 05 O 

CO N CD O 



o (M 

lO CO r-l 



C3 q 

CO 



^+1 -H 1?^ 



1 C'l -H C (M 1 



^ CO 05 ' 

: o CO c<i r-! ci d c-i i# 
o rt< 1-1 



1 CO ".O S-l o o o 



(M CO (N (M r H CO ■ 

CO 02 CD CO CD CO 
N 1-1 CO 



O CO o 

o -t< 
o c<i --o 

d ct: d 



r-l O -f< 

O t~ CO CO 
05 CO C2 O 



C2 O >0 C3 
05 CO Oi CO CO 

O CO CM c; 

rH Co" (N S<j 
r-l CO 



i-^i-'OCO^^CO^OiOi— I 
-Hr-l-HOCOCOrHOSO 

oo(Nc<ico_ini-i-t<io 

I* CO CO Co' r-I d CO 



-H CO -H 'Ol 

c: O to :o 
IM OO CO (M 



O 05 O CO CD t~ rH I 
1-1 C: (X O r-H I 

CO <M 00 c;3 iQ o o ■ 



■^COC35(MCDr-lOr-lOO 
CDIMOCOCOt^OOCO 
t^OOrJlTfHCM^iOCOOi 



CO 1-1 lO O 



o CO : 



O rH 

CO (M 

o o 



CO O -)< CO O ' 



COOOOCOrHO— lOi— I 
^(MCOCOO-H-Ht^-^l 
COCOOO CiCScprHrH 

cococog^ocoodco 



COr-l<MlO<M(M^i-liO 
■^COrHt-0 0505-*(M 
CnCOCOrHqCOr-lrHOi 
id r-i d 1?^" r-i id CO rH 



o; C2 o 
-H -+i 



1-1 OO C^l (M CD 



oiCi-i(Moinooo 

(Mr-ii-lCOCOOOCO-tl 

co(MTtia5COt--*r^o 



(M CO 

o o 



§ g 



1 CO 1-1 



) oi 00 i-i 



o d ^ 



(MNlOOlrHOCOCqO 



® 3 



O o . 

S 1§S 

- -So 
a '^C 

o 5 
o p.^^ 
tfi 1j o 

ce O 
S O 

So 



CO 1-4 CO o 



GO o 00 o o 

~ CO 1-1 (M CO O 
(M (M CO t~ OS 



CO C O CO CO o < 
r-l 1-H O CO <M I 
^ CO rH lO ICl 



. 9^ P< 

o o 
CO V ¥ 

o o o 

ai O o 

^3:3 



o 'o 

a a 



'^a 

b o q-i 



a a a 



'to 

05 t- (M 

d (^i 



136 



OBSEEVATIONS ON 



The blood in No. 1 was abstracted from a stout, muscular Eng- 
lish seaman, who had been exposed to the malarial poison in Jack- 
sonville, Florida, and in Savannah. 

Before the commencement of the bloodletting the skin was hot 
and dry, face flushed and red, respiration thoracic, pulse 106, tem- 
perature of hand 105, temperature under the tongue 106. The 
pulse was full, and the respiration deep and rapid. There was a 
rapid introduction and distribution of oxygen, and a corresponding 
increase of temperature, denoting an increase of chemical change. 
The patient complained of great pain in the head. 

The patient appeared to be alarmed by the preparations for 
bloodletting, and when I appeared with the specific gravity bottles, 
beaker-glasses, and capsules to receive the blood, he fell back (he 
w^as standing) into the arms of the assistant, and in a few moments 
before the lancet was applied the perspiration stood in large drops 
upon his face and hands. During the bleeding he perspired freely, 
and fainted before fix were abstracted. The pulse and respiration 
were diminished in frequency and force, and the patient fell into a 
profound slumber, during which his clothes were saturated with a 
profuse perspiration. The temperature in the course of three hours 
was reduced to the normal standard, and the pulse and respiration 
diminished in frequency and force. 

This case yielded readily to the action of sulphate of q.uinia, and 
was discharged three days after this observation. 

The fact that the mere preparations for bleeding caused the 
patient "to break out into a profuse perspiration," may be accounted 
for in two ways. Either the cerebro-spinal system acted upon the 
sympathetic nervous system, and thus influenced the circulation, 
respiration, and skin^ and through the circulation and respiration 
the chemical changes ; or the sweating stage was nigh at hand, and 
the bleeding was the occasion and not the cause of its appearance. 

Tn this case, the true explanation, which we will endeavor to 
substantiate hereafter by numerous facts, appears to be that the 
malarial poison excites the sympathetic and cerebro-spinal nervous 
systems, either by a direct action upon the nervous apparatus, or 
by an indirect action, by inducing chemical changes in the blood, 
especially in the blood-corpuscles, the altered products of which act 
as excitants to the nervous systems. Through the agency of these 
two systems, especially of the sympathetic, the respiration and cir- 
culation are increased in frequency and force. In other words, the 



MALAKIAL FEYER. 



137 



elements and conditions of chemical change are rapidly supplied to 
all parts of the body; hence the heat of fever. During these 
changes the poison is drawn into the round, altered, and rendered 
no longer an irritant to the nervous system. The same thing may 
be true of the altered, offending compounds of the blood; during 
these chemical changes they may be broken up and thrown off, or 
so altered as to be no longer excitants to the nervous systems. 
The nervous systems, when these offending compounds are removed, 
no longer excite the respiration and circulation. Another reason 
why nervous action may be diminished periodically, is found in the 
chemical changes going on in the nervous apparatus itself. If nerv- 
ous force result from chemical change, and if the amount of nervous 
force corresponds to the chemical changes of a definite amount of 
matter placed in a definite position, then vigorous nervous action 
must always be attended by rapid alteration of the elements of the 
nervous system, and by a correspondingly rapid exhaustion of nerv- 
ous force, and the action then would cease for the same reason that 
the action of an engine ceases when all the fuel is consumed. These 
views are substantiated by the fact, that in malarial fever a high 
temperature is almost invariably attended by a remission or inter- 
mission, and is a favorable symptom ; whilst the want of a high 
temperature, as in congestive fever, is always a dangerous symp- 
tom, signifying profound alterations in the nervous system, and in 
the muscular structures of the heart. 

The blood of this patient presented a dark, almost black color, 
which, upon the surface of the clot, changed to a bright red arterial 
hue after two hours' exposure to the atmosphere. The coagulation 
appeared to be a little slower than usual. The color of the serum 
was light golden. The color was not of the bright, deep golden 
yellow, which, as far as my experience extends, is the invariable 
color of the serum in the severer cases of malarial fever. 

This patient had been sick but five or six: days, and the fever 
was intermittent and of a mild type, and the changes of the blood 
were correspondingly small. The blood-corpuscles, and albumen, 
and fibrin were slightly diminished; the extractive and coloring 
matters were slightly increased, and the mineral matters were nor- 
mal in amount. 

The blood in No. 2 was abstracted from a thin, sallow, anemic 
French laborer, who had been living and working in a low mias- 
matic situation on Thunderbolt road, and had been sick with chill 
10 



138 



OBSERVATIONS ON" 



and fever for five weeks, without any medical attendance. The 
effects of the miasmatic fever were well marked in the reduced 
flesh, feeble forces, sallow anemic complexion, and pale lips and 
gums, and in the neuralgic pains of the head. 

The pulse and respiration during the intermissions were normal, 
whilst the respiration was slightly increased, and the temperature 
of the trunk and extremities slightly diminished. 

The blood coagulated in the usual time, and the clot was firm. 
After standing four days in a stoppered bottle, in the heat of sum- 
mer, the clot appeared firm, undecomposed, and the serum clear. 
The blood of a patient who was suffering from the effects of remit- 
tent fever and severe salivation, placed by the side of this, in the 
same time, and under the same circumstances, had its clot com- 
pletely disintegrated, and commenced to putrefy. 

This analysis confirms the statement that the malarial poison 
(either directly or indirectly) destroys the colored blood-corpuscles. 
They are diminished one half, the dried corpuscles being only 
73.405, and the moist corpuscles 293.620 ; whilst in health the dried 
corpuscles generally average 135.000^ and the moist corpuscles 
540.000. The fibrin and mineral matters existed in the usual 
proportion. 

The blood which furnished the analysis No. 3 was drawn from the 
arm of a thin, sallow, anemic Irish laborer, who had been living 
and making bricks in a low miasmatic situation, and had suffered 
with chill and fever for six weeks. Flesh reduced ; complexion 
sallow, anemic ; lips, gums, and tongue pale. This patient is 
exhausted by slight exertions, and complains of great weakness. 
Inferior extremities slightly oedematous. The pulse, respiration^ 
and temperature were variable; sometimes above and at others 
below the normal temperature. 





Sept. 16th. 


Sept. 17th. 


Sept. ISth. 


Sept. 19t 


Sept. 20th 


Pulse 


88 


72 


72 


76 


96 


Respiration .... 


24 


20 


20 


24 


24 


Temperature of atmosphere . 


87.5° F. 


86= F. 


88.0= F. 


89= F. 


83= F. 


" of hand 


100.5 


90 


98.5 


98 


100 


" under tongue 


101.25 


98 


99.5 


99 


102 



The reduction of the nervous and physical forces was attended 
by a reduction in the solid constituents of the urine. 

Thus, upon Sept. 17th, 16,027 grains of light-colored urine were 



MALARIAL FEVER. 



139 



excreted during the twenty-hours, which contained only 68.482 
grains of solid matters, composed of 42.681 grains of urea, 1.280 
of uric acid, 18.776 grains of extractive and coloring matters, and 
5.696 of mineral matters. Under the action of sulphate of quinia, 
and infusion of Virginia snakeroot, the solid matters of the urine 
increased rapidly in amount, and soon corresponded to the normal 
amount. 

The blood of this patient was watery in appearance, and coagu- 
lated slowly. 

Eeaction decidedly alkaline. 

After standing twenty hours the clot contracted but little, and it 
was soft, possessing but little consistency. In the specific gravity 
bottle the colored blood-corpuscles gravitated towards the bottom, 
and left above a transparent, light yellow clot. 

Serum of a light yellow color. 

This examination of the blood shows, that the continued action 
of the malarial poison had reduced the colored blood-corpuscles to 
51.987 dried, or 207.948 moist, which is only a little more than 
one-third of the normal standard. 

The fixed saline constituents of the colored blood-corpuscles were 
not only correspondingly, but absolutely diminished in amount, 
whilst the fixed saline constituents of the liquor sanguinis were 
normal in amount. 

Notwithstanding the formation of the buffy coat, the fibrin was 
diminished, as well as the colored blood-corpuscles. 

The blood in No. 4 was abstracted from the arm of a muscular, 
well-built English seaman, who had been exposed to the malarious 
influence when sleeping aboard his vessel, lying in the Altamaha 
river, opposite the town of Darien, and when running up and down 
the Savannah river, from its mouth to the city of Savannah, in a 
steam tug. 

The fever was preceded by a chill, and was of the remittent 
type. The symptoms were indicative of great danger — tongue red, 
dry, harsh, and rough ; skin hot, dry, and harsh ; pulse accele- 
rated; respiration panting, thoracic, and greatly accelerated; thirst 
intense ; expression of countenance anxious ; intellect dull and 
often wandering; urine high colored, concentrated, and rich in 
coloring matters and urea. The dry, red, glazed tongue ; the dry 
skin ; the panting, accelerated respiration, and the wandering in- 
tellect, were dangerous symptoms, indicating the decided action 



140 



OBSEEVATIOXS ON 



of the poison -apon the cerebro-spinal and sympathetic nervous 
S3^stems, and upon the circulatory and respiratory apparatus. The 
elevated temperature, and high-colored urine, rich in solid matters, 
v/ere, on the other hand, favorable symptoms, because they indi- 
cated the existence of chemical actions which would result in the 
modification of the malarial poison, and the destruction of the nox- 
ious compounds formed in the blood. The following table will 
illustrate the prominent symptoms: — 



MALAEIAL FEVEE. 



141 



•s.moq \z 
paja.ioxe auun 
9i{j III sjnan}i;s 
-noD annus paxi^j 


.S O -H 00 • •• >0— 'ICCOCOOO'-'. 

CO IQ O • • • Tj< CO lO O lO • • • • 

o 


paia.ioxe s.iai 
-nuu SuuoioD 

pUK dAl}0T3.HX3 


Grains. 
253 

270 
185 

147 
252 
169 
214 
449 


•sinoq 

fZ JOJ piou OUfl 


00 CO T*< • • • J>- O CD l>. 05 r-H • • . . 

S r)H Tj4 t-.' * *' diodcoodoj'"'* 

O rH rH 


•s.iq f 5 Snunp 
pa^ajoxa uaa^ 


Grains. 
623 

669 
790 

679 
267 
140 
212 
203 
197 


•sinoTi 
SuLinp pajajD 
-xa sjajvEut pipS 


Grains. 
811 

999 
1112 

4.52 
465 
432 
481 
916 


•s.iq fz Snunp 
pajaaoxa j.qivjw 


Grains. 
11428 

14294 
19210 

8581 
13186 
6057 
9238 
13023 


•sjq fz Snunp 
pa;a.ioxa anun 


Grains. 
12210 

15291 
20383 

19118 
8038 
13652 
6190 
9720 
1.3910 
15903 
21210 
32320 
23300 


•auuTi JO 
AnwjS oppads 


1020.0 

1019.6 

1019.3 

1020.0 

1021.0 
1022.0 

1025.0 
1016.5 
1018.2 
1022.2 
1020.0 
1018.0 

10*10. 0 
1008.0 


•anSnoj jap 
-un ajn^naadniaj, 


105.^0 
105.0 

101.8 

102.5 
101.5 
100 0 

102 0 
99.0 
99.0 
99.0 
99.0 
99.0 
99 0 
99.0 

99'. 12 

1 


•pntiq 
JO ajnjuaaduiajj 


103.00° 
103 25 

101.00 

100 75 
99.16 
97 00 

99.00 
91.05 
96.00 
97.00 
95.90 
96.00 
96.25 
97.00 

97.08 


•ajaqdsoui^'B 
JO a.in}i!.iadraaj. 


0 

rH 0 0 0 0 0, OOOOOiCOO.O 

d r-' Co' CO I--;-*jt>I|>;i>;-HOcd,-H 

oo OD 00 00 00 OOOOOOQOOOCOOOOOOO 


noT^j'BJidsajj 


0 -H CD <M to 
GO ~V T ^ '^'^ 0O-Hlr-'^|'cO-H'+'-".(M 

CO 't^ IM <M <M 


•asiuj 


0 CO 0 0 0 (MO COOt^CDt H-H-H.-W 

01 CO 03 !>• lOCD 0 0-*i'*^'tlTtlTtH>-# 


State of Tongue, Skin, and 
Intellect. 


Tongue dry, red, superior portion 
coated with black fur; skin hot 
and dry; intellect dull. 

Tongue dry, red, and glazed, feels 
rough ; skin dry, harsh, and hot ; 
intellect dull; countenance anx- 
ious. 

Tongue — tip clean and red, superior 
portion coated with dark fur; 
skin moist and hot. 
Tongue cleaner and moister, still 
red at tip and edges ; skin moist. 
Tongue moist, still redder than 
normal. 

Do do. do. 
Tongue slightly coated with light 
yellow fur, soft and moist; skin 
normal. 

Do. do. do. 

Do. do. do. 

Do. do. do. 

Do. do. do. 

Do. do. do. 

Do. do. do. 

Do. do. do. 

Do. do. do. 

Do. do. do. 

Do. do. do. 


Hour of 

DAY. 


7 P. M. 

11 A. M. 

7 P. M. 

12 M. 

9 P. M. 

11 A. M. 

6 P. M. 

1 P. M. 

10 A. M. 

7 P. M. 

12 M. 

8 P.M. 

11 A. M. 

12 M. 
12 M. 
12 M. 
12 M. 


Date. 
1857. 


0 r-i I— 1 <M 01 COCO -t<"0i0C£>t01:^C005Ogq 



142 



OBSERVATIONS ON 



The blood of this patient was abstracted upon the 16th day after 
the commencement of the attack of remittent fever, and during 
convalescence. 

The blood coagulated in the usual time, and the clot was firm. 
During the coagulation, the blood-corpuscles settled, and left above 
a transparent clot, about |th of an inch in depth, and of a light 
yellow color. Color of serum, light yellow. This analysis shows 
that the dried organic residue, and especially the fixed saline con- 
stituents of the colored blood-corpuscles, have diminished. 

The moist blood-corpuscles are less than the normal number, by 
near 100 parts in the 1000 parts of blood. The fixed saline con- 
stituents of the colored blood-corpuscles were less than one-half 
the normal amount. 

This patient was treated with large doses of sulphate of quinia, 
stimulants, and nutritive diet; and this mode of treatment, combined 
with the vigorous chemical actions, as indicated by the high tem- 
perature, were, without doubt, the causes which preserved, to a 
great extent, the integrity of the blood. 

The blood in No. 5 was abstracted from a young Scotch seaman, 
aged fourteen years, with light hair, blue eyes, florid complexion, 
and sanguine nervous temperament. This patient had been much 
exposed to the sun and the night air, upon the light-ship lying at 
the mouth of the Savannah River. 

During the height of the fever the face was as red as scarlet; the 
tongue dry, red, and rough; tip and middle clean, and of a bright 
red color; posterior portion coated with dry yellow far; surface as 
dry and harsh as a rough board; lay in a stupor, it w^as almost 
impossible to arouse him ; manifested great tenderness of epigas- 
trium; pressure here causes him to cry out. The following table 
will illustrate the condition of the pulse, respiration, temperature, 
skin, tongue, and intellect : — 



MALAKIAL FEVEE. 143 













o 


o 


6 








Date. 


Hour 


State of Tongue, Skin, 




ation. 


ratur 
spher 


ratur 


p a 

-1^ o 
ci 


c gra^ 
ine. 


if urii 
:ted. 


Charac- 
ters OF 


OF DAY. 


AND Intellect. 


6 

m 
'3 


CO 




is 


II 

i§ 


Specifi 
of ur 




the Urine. 








PH 








Eh 


< 




Sept. 16 


7 P. M. 


Skin of face as red as scar- 


100 


24 


88.0° 


102.00° 


103.25^ 


Grs. 






1857, 




let, skin of body in a pro- 
fuse perspiration ; tongue 
rough and perfectly dry ; 
intellect in a stupor ; can- 
not be aroused. 


















" 17 


11 A. M. 


Skin and tongue moist and 
relaxed ; intellect clear. 


86 


18 


87.0 


100.25 


101.00 


1008.2 


12078 


Light 
orange 
color. 


" 18 


12 M. 


Tongue coated with yel- 
low fur, much dryer than 
normal ; intellect wan- 


98 


32 


87.5 


103.00 


104.00 


1010.0 




Light straw 
color ; urea 
and uric 






dering. 
















acid dimi- 




















nished. 


" 18 


8 P. M. 


Tongue bright red, dry, 
rough, and harsh ; lies in 
a profound stupor. 


90 


26 


85 0 


102.25 


103.25 








" 19 


11 A. M. 


Tongue moist, red at tip 












1004.0 




Light 






and edges, and coated 
with white fur ; intellect 
















orange 




















color. 






bright. 


















" 20 


12 M. 


Tongue moist ; intellect 
clear. 












1001.0 


30013 


Light 
yellow 
color. 


" 21 


1 P. M. 


Tongue moist and pale ; 
intellect continues clear. 


66 


18 


83.0 


98.00 


100.00 


1006.0 


10000 


Deep 
orange 
color. 


" 22 


12 M. 


Tongue, skin, and intel- 
lect normal. 


65 


18 


84.5 


98.00 


99.50 


1004.0 


20800 


Normal in 
color. 


" 22 


7 P. M. 




57 


16 


81.0 

1 


98.00 


99.05 


1003.0 


21063 


Light 
colored. 



The pulse throughout was much feebler than in " healthy cases" 
of malarial fever. It is worthy of note, that the urine excreted dur- 
ing the delirious state was light colored, and of low specific gravity. 

In this case, as in the preceding one, we cast aside the advice of 
many of the older writers, and administered the sulphate of quinia 
and stimulants freely in the first stages of the disease, regardless 
of the glowing parched tongue, tenderness upon pressure of the 
epigastrium, severe headache, high fever, rapid pulse, thoracic full 
respiration, hot, dry skin, and wandering intellect. Under the action 
of sulphate of quinia, cut cups, stimulants, and sinapisms, the dry, 
red tongue became moist, clean, and pale ; the circulation and 
respiration abated in force and frequency, the dry, harsh skin was 
covered with perspiration, the intellect returned to its normal 
actions, and all the symptoms subsided. 

In the present case, sinapisms, blisters, cut cups, and purgatives, 
diminished the apparant congestion of the brain temporarily, but 
not permanently. Stimulants and sulphate of quinia, so far from 
increasing the cerebral disturbance, diminished it permanently, and 
relieved the intellectual faculties. Under their action, the red, dry, 
rough tongue became pale, moist, and soft — under their action, the 
circulation and respiration were equalized, and diminished in fre- 



OBSEEVATIONS ON 



quency; the temperature was dimiaished, and the intellect restored 
to its normal exercise. 

The blood was drawn on the 10th day after the commencement 
of the malarial fever, during convalescence. 

The clot appeared to be softer than normal. 

Serum of a light yellow color. 

The chemical examination of the blood showed that the organic 
matters of the colored blood- corpuscles were diminished slightly, 
whilst the mineral matters w^ere greatly diminished. The fibrin 
was considerably below the normal standard, and appeared to be 
softer than normal. The organic matters of the serum were some- 
what below the normal standard. 

When we consider that this patient was in a state of almost com- 
plete starvation, during the height of the disease, it is evident that 
the malarial poison acted but slightly upon the constituents of the 
blood. The malarial poison appeared to act almost entirely upon 
the brain and nervous system. Daring the height of the disease, 
I had no hopes whatever of his recovery, so alarming were the 
cerebral symptoms. Long after the pulse and respiration, skin and 
digestive functions were restored to their normal actions, the patient 
was scarcely able to stand or walk, on account of the condition of 
the brain. His first efforts at walking resembled those of an in- 
fant, just learning to stand and walk alone. This was not due to 
the loss of muscular power, for there had been but a slight reduc- 
tion of the size of the muscles. It was due rather to the disordered 
state of the cerebro-spinal and sympathetic nervous systems. The 
action of the malarial poison upon the brain and nervous system 
was, without doubt, greatly increased by peculiarities of constitu- 
tion, irregularities of habit, and continued exposure to the hot sun 
on the light-ship. 

I was afterwards informed that this boy was in the habit of using 
ardent spirits freely. It is probable that one or all these causes 
may have predisposed the brain and nervous systems to derange- 
ment, and interfered with the healthy action of the organs, and 
converted a light attack into a severe and dangerous disease. 

It is probable that the dose of malaria was small, and aside from 
these circumstances, would have produced only a mild disease. 
"We are led to this conclusion by the fact that its effects upon the 
blood and excretions were comparatively slight. 

The blood marked No. 6 was drawn from the arm of an Ameri- 
can seaman, six hours before death. This patient had been run- 



MALARIAL FEVER. 



145 



ning up and down the Savannah River in a steam tug, and was 
attacked with chill and fever, which assumed the remittent type after 
four days' recurrence of the chill. During his sickness, the disease 
bore a blended likeness to both remittent and typhoid fevers, and 
after death the organs exhibited the existence simultaneously of 
both diseases. 

The following table will give a condensed view of the symptoms: — 



Hour 

OF DAY. 



State of Toxgue, Skin, 
AND Intellect. 



BE S§ 



- - 1- c3 



Characters of Urine. 



Aug. 7,11 A. 
18j7. 



A. M. 



8 11 A. M. 



6 P. M. 



10 9 A. M. 



10 11 A. M. 



11 10 A. M. 



Skin hot, but in a profuse 
perspiration ; tongue coated 
with light yellow fur ; res- 
piration hurried, thoracic ; 
chest heaving ; intellect stu- 
pid, torpid ; it is difficult to 
arouse him, and then his 
answers are incoherent ; 
bowels loose 

Skin hot and dry; continues 
stupid; bowels loose. 



Skin moist ; body has a pecu 
liar offensive smell ; breath 
offensive ; stools very offen- 
sive ; intellect stupid ; low 
muttering delirium. 

All symptoms much worse ; 
passes his urine and feces in 
bed ; has a pustular erup- 
tion over the surface of the 
trunk and limbs ; surface of 
blister red and raw ; the 
stools dark colored and fetid. 

No improvement of symp- 
toms ; tongue dry ; blister 
dry and red ; bowels loose ; 
skin not so warm ; pulse 



112 



81.0° 



112 



so.o 



80.0 



101:° Urine clear, limpid, 
deep orange color. 



103.0 :ioi 



103.5 



Continues to grow worse. 



Do. 



do. 



12 8i 



Almost entirely insensible ; 
lies with mouth and eyes 
open; his elbows, shoulders, 
and hips, upon which the 
weight of his body has rest- 
ed, are of a dark purple 
color, and the skin is com- 
mencing to slough at those 
parts most exposed ; tongue 
dry and rough ; teeth coat- 
ed with sordes. 

Died. 



10-t.O 



Urine reddish orange, sp. gr. 
1013; 1000 parts contained — 
water 957.282, solid matters 
42 618, urea 7.108, uric acid 
0.394, extractive and color- 
ing matters 32.570, fixed 
salts 2.621. 



Urine of a bright reddish- 
brown color, cloudy, with 
epithelial cells from the 
mucous membrane, blad- 
der and urethra, and with 
mucous corpuscles and 
spermatozoa. 



Urine of a bright red color, 
sp. gr. 1012.6; contains albu- 
men; reaction strongly acid. 

I Urine bright red color; after 
standing 12 hours, a heavy 

j deposit of triple phosphate 

i fell ; contains albumen. 

Urine a shade higher than 

i normal ; reaction acid ; sp. 

! gr. 1013.2; after 12 hours, 
let fall a light yellow deposit 
of triple phosphate, urate 
of soda, and spermatozoa ; 
1000 parts contained — water 
961 .112, solid matters 3S.S88, 
urea 12.304, uric acid 0 592, 
extractive and color'g mat- 
ters 22.259, fixed saline con- 
stituents 3.333. 

Urine, passed just before 
death, normal in color; sp. 
gr. 1011.3; reaction acid; 
1000 parts contained — water 
972.728, solid matters 27.272, 
urea 5.228, uric acid 0.158, 
extractive and color"g mat- 
ters 18.543, fixed saline con- 
stituents 3.030. 



146 



OBSEEVATIONS ON 



The body was examined four hours after death. The exterior 
was of a universal sallow color. 

The muscles were full and well-developed, and appeared to have 
lost but little flesh during the progress of the disease. 

The membranes of the brain presented a normal appearance, and 
the substance was firm, and not more congested with blood than 
normal. 

The appearance of the structure and condition of the brain, and 
its bloodvessels, and membranes, did not correspond to the condi- 
tion of softening which the cerebral symptoms led us to expect. 

The brain was not examined microscopically, and there may 
have been minute changes in the delicate structures, chemical or 
physical, which escaped the observation of the naked eye. This is 
possible, but not probable. It is hardly probable that profound 
alterations could take place in so delicate an organ as the brain, 
without some changes in its color or consistence, palpable to the 
naked eye. 

Heart and lungs normal. 

The liver presented the true malarial hue; slate-colored upon 
the exterior, and dark bronze in the interior. 

The bile was of a greenish-black opaque color when seen in 
mass, and of a gamboge-yellow color when spread out in thin 
layers. The structures of the liver presented the usual consistence. 
The liver-cells, under the microscope, appeared to be a shade darker 
than usual ; but presented the usual shape and appearance. 

No trace of grape-sugar was discovered in the liver. The blood 
of the liver was dark, and did not change to the arterial hue when 
exposed to the oxygen of the atmosphere. 

The filtered decoction of the liver presented a bright golden 
color, similar in all respects to the color of the serum of the 
blood. 

The spleen was slate-colored, enlarged, and softened. The tissues 
gave way readily under gentle pressure. The dark, reddish-brown 
pulp of the spleen consisted of numerous colored and colorless cor- 
puscles, and did not change to the arterial hue when exposed to 
the oxygen of the atmosphere. 

The mucous membrane of the stomach was colored yellow with 
bile, and the bloodvessels were filled with blood, and several spots 
of the mucous membrane were more engorged with blood than the 
rest of the surface ; but to the naked eye there was no softening or 



MALAKIAL FEVER. 



147 



marks of inflammation, and no pathological alterations beyond the 
mere stasis of the blood in the capillaries. 

The color of the intestines, externally and internally, was darker 
than usual. The small intestines contained fecal matters, epithelial 
cells, mucous corpuscles, and mucus colored yellow by bile. Blood- 
vessels of the mucous membrane of the small and large intestines 
injected with blood. The mucous membrane was most injected 
with blood, and presented a purplish color in the last eight feet 
of the inferior portion of the ileum, and the engorgement of the 
bloodvessels was greatest in the Immediate region of the ileo-caecal 
valve. 

The solitary glands were numerous, enlarged, elevated, and dis- 
tinct, and of a brown color. When the intestines were held up to 
the light, bloodvessels engorged with blood were seen passing to 
each gland. The bloodvessels supplying the solitary and Peyer's 
glands were more engorged with blood than those supplying the 
mucous membrane generally. These solitary glands were most 
numerous in the neighborhood of the ileo-cascal valve, and were 
found scattered over the superior portion of the colon, and over 
the csecum, and over eight feet of the inferior portion of the ileum. 

Peyer's glands were enlarged and elevated. These glands were 
of various sizes, from one quarter of an inch to three inches in 
length, and from a quarter of an inch to half an inch in breadth. 
They occurred at intervals of from one to two inches from each 
other, and extended from the ileo-cascal valve, along the mucous 
membrane of the ileum, for about nine feet. The bloodvessels 
around these glands were engorged with blood. This part of the 
mucous membrane of the ileum, studied with the solitary and 
Peyer's glands, was far more injected with blood than the stomach, 
jejunum, or superior portion of the ileum. Although these glands 
were enlarged, elevated, and injected with blood, still they could 
not by any means be compared to the condition of these glands in 
an advanced stage of typhoid fever. 

From this examination we are now able to present a condensed 
statement of the prominent symptoms and alterations of the solids 
and fluids. 

The pulse was feeble, and varied from 104 to 132 beats in the 
minute; the respiration was hurried, thoracic, and varied from 36 
to 47 in the minute; the temperature under the tongue varied from 
104° F. to 105°; the temperature of the extremities varied from 
103° to 104°; the temperature of both the trunk and extremities 



148 



OBSEKVATIONS ON 



was remarkably uniform ; the state of the skin varied, sometimes 
dry, and at others bathed in perspiration ; the tongue was dry and 
coated with fur; and towards the termination of the disease, the 
tongue and teeth were coated with sordes. It is evident from these 
facts that there was no distinct remission of the febrile excitement. 

The urine was copious; of low specific gravity; of higher color 
than normal in the earlier stages of the disease ; but twenty hours 
before death it changed back to its normal color. The urine 
contained small quantities of albumen. The urea was diminished 
relatively to the extractive matters ; we cannot say absolutely, 
because the whole amount of urine excreted was not determined. 
The extractive matters were increased relatively to the other con- 
stituents of the urine. The uric acid was normal in amount. 

The blood exhibited profound alterations ; the dried colored cor- 
puscles were only 65.612, and the moist colored corpuscles 262.448, 
in the thousand parts ; many of the colored corpuscles were altered 
in shape and appearance, and had in a great measure lost the power 
of changing from the venous to the arterial color, and many of them 
united together and formed rolls, as in the blood of inflammation ; 
the color of the venous blood, when first abstracted, was dark pur- 
ple, almost purple, and after exposure to the oxygen of the atmo- 
sphere the surface of the clot changed to a cherry-red color,' and 
not to the bright red color assumed by the surface of healthy venous 
blood when exposed to the atmosphere ; the serum was of a golden 
color, and low specific gravity ; the albumen was diminished, whilst 
the extractive matters of the serum were increased ; the mineral 
matters of both the blood-corpuscles and liquor sanguinis were 
diminished relatively, but not absolutely; that is, their diminution 
corresponded with, but did not exceed the diminution of the other 
elements of the blood. 

The pustular eruption, the offensive smell, the stasis of the blood 
in the parts of the body exposed to pressure, and the tendency of 
these parts to slough, all indicated alterations in the constitution 
of the blood, and derangement of the capillary circulation. 

The loss of muscular power, exhaustion, stupidity, coma, low 
muttering delirium, insensibility to pain, all indicated derange- 
ment of the cerebro-spinal system. 

The alterations in the actions of the capillary and general circu- 
lations, and of the respiration ; the profound alterations in the 
blood ; the alterations of the secretions and excretions, and of the 
structures of the liver and spleen, and of Peyer^s, and of the soli- 



MALARIAL FEVER. 



149 



tarj glands of the intestines, were all indicative of derangements of 
the sympathetic system of nerves. 

Oar knowledge of the early symptoms, and pathological changes 
of this case, do not permit an arbitrary decision as to which system 
of nerves was affected primarily. The fact that the post-mortem 
examination revealed (to the naked eye) no prominent lesions of 
these two systems of nerves, would seem to indicate that the poison 
or poisons acted primarily upon the blood, destroying and altering 
the blood-corpuscles, the active agents in the elaboration of the 
elements of the secretions, and of the muscular and nervous sys- 
tems. When the proper chemical changes in the blood were 
altered, when the compounds for the secretions and nutrition of 
the nervous system were altered, or not elaborated, then both the 
cerebro-spinal and sympathetic systems, manifested aberrated ac- 
tion. As the circulation and respiration, and the secretions and 
excretions, and the action and integrity of the organs depend, in 
great measure, upon the integrity of the nervous system, it is evi- 
dent that the derangement of the cerebro-spinal and sympathetic 
systems, through the derangement of the blood and secretions and 
excretions, would in turn act in concert with the disturbing agent 
or agents, and thus still greater derangements of the solids and 
fluids would be produced. 

The opinion of Hoffmann; Boerhaave, Cullen, Selle, Tode, Thorer^ 
Stoll, J. C. Frank, Fodere, Clutterbuck, Alibert, Kayer, Nepple, and 
others, which referred fevers to a lesion of the nervous system, 
was adopted and extensively applied by Maillot,^ in his original, 
elaborate, and invaluable work on malarial fever. M. Maillot 
looked upon the cerebro-spinal axis as the point of departure of 
the series of morbid actions constituting periodical fever, and 
affirmed that an acute irritation or hypersemia of the great nerv- 
ous centres existed during the active stages of malarial fever. In 
this country, my colleagues. Professors Lewis D. Ford^ and L. A. 

' Traite des Fievres ou Irritations Cerebro-Spinales Intermittentes d'Apres des 
Observations recueillies en France, en Corse, et en Afrique. Par F. C. Maillot. 
Paris, 1836. 

2 It thus appears that of these forty cases of intermitting and remitting fever, 
this tenderness on pressure of some portion of the spinal column was present in 
all but four cases of remitting fever, and in two cases of intermittent ; of these, 
however, one was arrested by a blister to the spine, without other means used but 
dieting, and the other was modified materially in its character in like manner." 
* * *_p. 354. 

*' Another question naturally presents itself : What is the force and value of this 



150 



OBSE'RYATIOXS OiN" 



Dugas/ simultaneous!}^ with the appearance of the work of Maillot, 
maintained that the phenomena of intermitting and remitting fevers 

symptom ? whence tins uneasiness ? what does its existence indicate ? Certainly 
not that the skin at these particular points is sore and tender. I have examined 
carefully, to verify this fact, by taking it up between the thumb and finger, and 
compressing it with more force than was applied by the direct pressure ; uniformly 
receiving the assurance of the patient that the uneasiness was of a different cha- 
racter from that produced by pressure upon the bone. But if this might be the 
cause of pain in the method by pressure, it cannot be in that by percussion ; for 
it is well known to those who make use of mediate percussion that it may be 
employed freely even upon a blistered surface, without producing pain. It as 
certainly does not indicate that the hone itself is tender and diseased; for we can- 
not conceive why pressure upon a diseased bone should be followed by sighing, 
coughing, increased oppression of the prsecordia, nausea, and faintuess. It is as 
unsatisfactory, for the same reasons, to attribute this symptom directly to a dis- 
eased state of the ligaments of the vertebrse. 

" Having thus excluded these three parts from any participation in the production 
of this phenomenon, we next inquire. Can it proceed from a diseased state of the 
dura mater lining the bony channel ? We answer unhesitatingly that the symp- 
toms above referred to, developed in distant organs by the examination, cannot 
arise directly from an inflammation or any degree of irritation of the dura mater, 
for reasons assigned already ; but we can conceive very readily how the dura 
mater, being in a swollen state, might produce such symptoms by compressing the 
origin of nerves supplying these distant organs when an unusual degree of motion 
is communicated to the vertebrae by percussion. But we perceive that this unusual 
motion of the vertebra would produce the same degree of pressure if the dura 
mater were in its normal state, and the substance of the cord itself enlarged. We 
therefore must necessarily adopt the conclusion that this phenomenon indicates 
a diseased state either of the medullary substance of the spinal cord, or of its 
investing membranes. I am not prepared to infer from these few cases that this 
local affection of the spine always exists, nor that it is the primary irritation upon 
which these fevers depend ; but if subsequent observations shall establish the 
uniform existence of this spinal irritation at the commencement of intermitting 
and remitting fevers, it will confirm the opinion, now almost universally held by 
the profession, of the local origin of all fevers, and the equally universal persuasion 
that this location is in some part of the nervous system." — pp. 357-359.* 

1 " When, fresh from the benches of the school of organic medicine, I was called 
on to examine and to treat cases of ' bilious fever,' I instinctively interrogated in 
succession every organ of the body, in search of the seat of the disease, or, in other 
words, of the cause of so much constitutional disturbance. In some cases, despite 
all my investigations, no trace of disordered function (the best evidence of a dis- 
eased organ) could be detected elsewhere than in the stomach; in others the bowels 
were alone distempered ; other sets evinced the disturbance to be located in the 
liver, in the brain, or in more than one of the principal viscera. The bilious modi- 
fication implied by the name of the affection, though very frequently manifest, 



* Remarks on the Pathology and Treatment of Intermittent and Eemittent Fevers, with Cases. 
By Lewis D. Ford, M. D., Professor of Chemistry in the Medical College of Georgia. Southern Medi- 
cal and Surgical Journal, vol. i. Iv'o. 6, November, 1S36, pp. 33.7-3G0. 



MALAEIAL FEVER. 



151 



depend upon lesions of the cerebro-spinal nervous system; and, 
at the present day, my colleague, Professor Henry F. Camp- 
was often entirely wanting. Yet eacli of these cases presented certain characters 
peculiar to all. Their onset was always marked by loss of muscular power, by 
pains in various parts of the muscular system of animal life, &c. ; their early 
stage by intermittency, or decided remissions ; their duration and termination pre- 
sented a strong analogy ; in short, it was evident that although modified by the 
affection of some special organ, all these cases were under the predominance of an 
original and common aflfection. The seat of this original and common affection 
cannot be mistaken if we adhere to the principle already alluded to, that of regard- 
ing vitiated function as the best indication of diseased organs. If an organ be 
healthy, its function must necessarily be normal ; consequently, if a function be 
abnormal, the organ presiding over it cannot be in a physiological condition. I 
am aware that it will be urged that certain secretions may be vitiated by an 
altered condition of the fluid whence they are derived, without disease of the 
secerning organs. For example, the urine may present various aspects, according 
to the substances taken into the circulation, or the composition of the bile may 
depend on that of the blood. But this cannot afl'ect our position, for the condition 
of the blood itself depends entirely on that of the organs which form it, and of 
those whose office it is to eliminate its impurities. If it remains impure, the cause 
must be found in the vitiated action of the emunctories. 

" But, whether these principles of diagnosis be admitted or not, it is presumed 
that no one would, on reflection, refer the morbid condition of the contractility and 
sensibility of the muscular system to any other locality than the nervous centres. 
We have already stated the earliest symptoms of our fevers to be lassitude, loss of 
muscular power, and pains in the muscles of animal life ; also, that intermittency, 
more or less complete, always marks their early stage. We are, therefore, led to 
the conclusion that the nervous system is the original and common seat of this class 
of affections. I trust that I will not be misunderstood ; the term original being 
here used expressly to indicate that these fevers subsequently undergo serious modi- 
fications, from the supervention of other derangements. It is to these complica- 
tions we must look for the explanation of the various forms assumed by the fevers 
misnamed bilious, so that the proper definition of them should be an original 
affection of the nervous centres, subsequently complicated by phlogosis of some other 
organ or organs, which secondary disorder may either gain the ascendency of the primary, 
or merely mask and modify it." * * * — pp. 388, 389. 

"We have already stated that neither of the above complicating phlegmasise^ 
alone or unattended with spinal disease, could produce the phenomena common to 
all the forms of our 'bilious fevers,' and we have furthermore stated the primary 
lesion to be that of the nervous centre, or, in other words, of the spinal cord. If 
the primary affection remain uncomplicated, then we have a disease of the mildest 
form known, one which retains its peculiar characteristics, its paroxysmal form, 
and its periodicity. In short, we have a plain case of ague and fever, such as we 
daily see." * * *— p. 393. 

"The action of quinine will always be most happily seconded by revulsive appli- 
cations to the spine, which is frequently found painful on pressure or percussion. 
Indeed these will alone, in many instances, be found sufficient to arrest the disease. 
For evidence of this very decided effect I would refer to the interesting and able 



152 



OBSEKVATIONS ON 



bell/ advocates a similar theory. On the other hand, Professor 
John Fred. Lobstein^ and James Copland^ have ably and elabo- 
rately advocated the more probable theory that the malarial poison 
affects primarily and especially the sympathetic nervous system. 

paper published by Professor Ford in the sixth number of the Southern Medical 
and Surgical Journal.''^ — p. 394.* 

1 "As in the nervous system we recognize two grand departments — viz., 1st, the 
cerebro-spinal system, all the normal actions of which are subject to cessations 
and interruptions ; and, 2dly, the ganglionic system, all the normal actions of 
which are of a continuous and uninterrupted character — so in the manifestations 
of febrile diseases do we distinctly recognize two grand distinguishing character- 
istics respectively typefying the normal actions of these two systems of nerves ; 
thus a character of paroxysm obtains in certain cases, while a character of con- 
tinuousness as plainly marks the others. Again, as in the cerebro-spinal system 
we find that its normal action pertains almost exclusively to sensation and to 
motion, with only a secondary and comparatively somewhat remote influence 
(which we have termed excito-secretory) upon nutrition and secretion, while in 
the normal action of the ganglionic system the entire function is known to be to 
preside over nutrition and the secretions, so in paroxysmal fevers do we find intense 
pain, modified sensation, and symptoms allying them to neuralgic and convulsive 
diseases very prominent, while in continued fevers modified nutrition and altered 
secretion are the marked and most prominent characteristics. We would there- 
fore announce, as our classification of febrile diseases, two grand divisions of fevers 
corresponding with the two grand divisions of the nervous system, thus : — 

"1. Cerebro-spinal fevers. AW paroxysmal. The secretions and nutrition second- 
arily afl"ected. 

"2. Ganglionic fevers. All continued. The secretions and nutrition primarily 
affected. 

" Under the head of cerebro-spinal fevers we would place the whole family of 
paroxysmal fevers, whatever type they may assume, and also the various forms of 
neuralgia, which are nearly always intermittent, as well as the sthenic forms of 
traumatic fever, together with the fever accompanying simple pharyngitis, pneu- 
monitis, dysentery, and many other diseases of malarious districts."! 

The late Dr. Milton Antony published, in the year 1837, an interesting article 
upon spinal irritation, from which we select the following passages : — 

" Because spinal irritation is, indeed, the true cause of the most conspicuous 
phenomena, as is evident on the soundest principles of physiology, and proved by 
their correction by its removal, it so captivated the thoughts, not sufficiently 
chastised by time and experience, as (although itself an effect) to be considered 
the primary and efficient cause of all, to the neglect of all concomitant or ante- 
cedent phenomena, and even its own etiology. Inquiry, I say, stops here at the 



* Remarks on the Pathology and Treatment of Bilious Fever. Eead before the Medical Society of 
Augusta, by L. A. Dugas, M. D., Professor of Anatomy in the Medical College of Georgia. Southera 
Medical and Surgical Journal, vol. ii. No. 7, February, 1838, pp. 387-397. 

f Classification of Febrile Diseases by their Relation to the Nervous System. By Henry F. Gamp- 
bell, M. D., Professor of Anatomy in the Medical College of Georgia. Southern Medical and Surgical 
Journal, vol. xiv. No. 1, January, 185S, pp. 13-18. See also Transactions of the American Medical 
Association, 1858. 



MALAEIAL FEVER. 



153 



detection of the fact of spinal irritation, satisfied that here is the real, here the 
first, independent, and sole cause. The indication of its removal, and that alone, 
is, therefore, plainly drawn from the premises. And so strongly does the spell hold 
its sway over the rational mind that, although no evidence of the fact of spinal irri- 
tation can be apprehended, it is still believed so intimately connected with the 
other phenomena in relation of cause as to have its existence inferred from these. 

" Here are the errors I would expose. * * * To the inquiring mind I say this 
local phenomenon, so clearly and beautifully displayed, cannot fail to reveal another 
truth. Could this spinal irritation have occurred without having its own peculiar 
and appropriate cause ? Certainly not, as there is no efiect without competent 
causation. If, then, it have a cause, is it abiding ? Or has it been momentary, 
and, therefore, left only its effects to be corrected ? If the former, surely nothing 
can justify the neglect of such abiding cause of any train of phenomena when our 
object is the removal of that train. As well might we expect to heal a wound 
whilst the thorn which caused it continues to rankle there. Our experience 
justifies the belief that spinal irritation generally, though not always, is dependent 
upon an abiding cause, for we have often detected such cases and removed them, 
correcting thereby their effects without any prescription for these." * * * — pp. 581, 
582. 

" We find an intermitting fever attended with some degree of irritation about 
the spinal marrow. As spinal irritation seldom, if ever, exists idiopathically, shall 
we not rather look to it as an index pointing to other disorder ? In this case an 
inquiry is necessary into the pathological condition of the general system, or the 
various organs, under the existence of an intermitting fever. And here we find 
that the liver and the spleen sometimes are laboring under an obstructing torpor, 
which prevents that free transmission of blood through them which the great 
portal system demands. This is a fact that we know to exist ; and if we did not, 
it is susceptible of plain proof. 

" Now, suppose a given quantity of blood in the system at the moment of con- 
sideration as twenty-four pounds, and that one-twelfth, or two pounds, passes 
the portal system, whilst the other twenty-two do the other circulation. The 
abdominal fulness evinces the obstruction. If, now, we allow any obstructing 
cause in the route of the portal circulation, the liver is the only organ where we 
may suppose it located. Let us suppose that this obstruction is such as to trans- 
mit only half the quantity of blood in a given time. The unavoidable consequence 
and proximate efi"ect of this must be an increased fulness of the portal vessels. 
This accomplished to its utmost, and the next consequent must be their refusal to 
imbibe or receive more than half their natural quantity in a given time, or one 
instead of two pounds, and consequently, if the health were perfect in the former 
state, there is, to say nothing about the quantity of blood, a redundance of about 
four per cent. Following this inquiry, we perceive, therefore, local phenomena, 
and especially in non-resisting parts, and consequently a cause of irritation or of 
oppression." * * * — p. 585. 

*' In all these cases, therefore, we are bound to direct attention to the first seat of 
the obstruction and irritation. Let the partisan in medical doctrines have his 
choice of the horns of the dilemma, still is he bound to look to it as a cause, 
whether it be the local irritation alone acting through the medium of the nerves, 
or merely the effect of the sanguine plethora, already prescribed. And in case of 
the combination of both, he must look to the removal of the obstruction to circula- 
11 



OBSERVATIOXS OX 



tion, as well as the subduction of irritation in the primarily obstructed and irritated 
part."*— p. 586. 

2 " In reflecting upon the nature of intermittent fevers, I have thought that it 
might, perhaps, be found in the disorder and perverted action of the abdominal 
nervous svstem, and there appear, indeed, to be sufficient grounds to render this 
opinion probable : 1st. The cases of this disease are very rare in which the functions 
of the abdominal organs continue vigorous and entirely unafl'ected. 2d. The com- 
mencement of the paroxysms is often marked with vomiting. 3d. We experience 
daily that this disease is mitigated, and very often entirely removed, by the use of 
cathartics. 4th. A single emetic, when given previously, sometimes suppresses the 
paroxysm, and not unusually removes the whole disease ; from which it appears 
that this remedy makes an impression upon the solar plexus of an opposite nature 
to that which had produced the fever. 5th. "When the disease is either left to itself 
or maltreated, congestions are produced in the abdominal viscera, induration of the 
liver, intumescence of the spleen, etc., and the general morbid state is changed into 
a topical affection. This metamorphosis appears to me to prove that the morbid 
action prevails at first in all the plexuses, and afterwards migrates from one to 
another ; for it is first apparently disseminated in the whole territory of the gan- 
glionic system before it runs with impetus into a single plexus, which is commonly 
the splenic ; and as the vessels are under the influence of the nerves, it cannot be 
otherwise than that congestions should thus be produced in the vessels. 6th. The 
paroxysms of intermittent fever are tied down to a regular rhythmus, in conse- 
quence of their being radicated in the nervous system, upon which nature has 
impressed a law according to which they must perform their functions periodically. 

"Each nervous system, therefore, is obnoxious to its own diseases. But the 
mode in which the cerebral and spinal nerves and the nerves of the abdominal 
plexuses and ganglia are affected by disease is the same. As in the various kinds 
of convulsions, epilepsy, tetanus, etc., there is disorder in the voluntary nerves, 
even when no organic lesion can be discovered in them ; so the nerves of the tho- 
racic and abdominal viscera may be affected without any alteration perceptible to 
the senses. As the perverted action of the cephalic brain is reflected with great 
force upon the abdominal brain, so, in turn, does the latter react upon and over- 
whelm the former. And, finally, as the cerebral system, when it is stupefied, as it 
were, by the violence of disease, destroys life, in like manner, I believe, an analo- 
gous effect takes place in certain diseases in the solar plexus. ""f 

^ The articles on Fevers in Pr. Copland's Medical Dictionary are the most elabo- 
rate, learned, and philosophical with which I am acquainted, and correspond with 
the other articles in his gigantic work, which will ever stand a noble monument of 
industry, energy, perseverance, learning, and philosophy. The following quotations 
will present a bare outline of his views : — 

"The doctrine that the causes of fever jirst affect the cerebrospinal nervous system 
is invalidated by the following considerations : a. This system either does not send 
nerves or it supplies but few nerves, and those often indirectly, to the organs 
especially or essentially affected in idiopathic fevers, as the heart, bloodvessels, 
secreting viscera, lungs, &c. h. That the chief avenues to this system open to the 
invasion of the exciting causes are the organs of sense and the cutaneous surface. 



* Remarks on Spinal Irritation, br :M, Antonv, M. D., Professor of Obstetrics in tbe Medical Col- 
lege of Georgia. Southern Medical and Surgical Journal, vol. i. iS'os. 9 and 10, March, 1S37, pp. 
5S0-OS7. 

t A Treatise on the Structure, Functions, and Diseases of the Human Sympathetic Nerve, hj John 
Fred. Lohstein. Translated by Joseph Pancoast, M. D. Philadelphia, 1S31, pp. 121, 122. 



MALAEIAL FEYEE. 



155 



Of these, the sense of smell is the principal. Although this sense is evidently 
impressed by several of these causes when acting intensely, and admitting that the 
brain is somewhat affected in consequence, still the effect produced in this quarter 
seems inadequate to explain the chief, and far less the whole, of the early pheno- 
mena, c. In some instances the intense operation of the effluvia generating fever 
has produced its effects almost instantly, and even caused death itself with equal 
rapidity, a result which the total annihilation of the cerebral functions could not 
produce, but which would necessarily follow the interruption or suppression of the 
influence transmitted to the heart and lungs by the nervous system of organic life. 
d. The generation of fever within the body itself cannot be explained upon the 
supposition that the cerebro-spinal nervous system is primarily and solely, or even 
chiefly, concerned in the production of the disease, but may be readily solved by 
means of the nervous system of organic life, if we take into consideration its func- 
tions and structural relations, especially with the vascular system, the circulating 
fluids, and the excreting viscera, e. The early lesions, whether of function or of 
organization, characterizing the first as well as the advanced periods of fever, can- 
not be accounted for by assigning the cerebro-spinal nervous system as the 
primary seat of the disease ; for, 1st. As this system cannot influence the action of 
the heart and the state of the vessels, excepting through the medium of the 
organic nervous system, and this only to a very limited extent, changes in it do 
not explain the alterations of vascular action, and still less the vitiation of the 
blood. 2d. As it does not control animal heat, so it cannot induce those remark- 
able extremes and morbid states of temperature distinguishing the malady. 3d. 
As it does not supply nor materially influence secreting surfaces and glands, so it 
cannot give rise to those early changes of function which they present, nor to those 
lesions of structure which they often subsequently experience. 4th. As it does not 
materially affect the actions of assimilation and nutrition, so it cannot occasion the 
remarkable changes they present in fevers. And, 5th. As it does not present 
aberrations of function, in the slighter and simpler states of fever, equal in degree- 
to those manifested by the viscera, chiefly supplied by the nerves of organic life ; 
and as, when such aberrations supervene in a remarkable manner, they are gene- 
rally consequent upon those of the organic nerves and vascular systems, and of the- 
blood itself, so that the primary impression made upon it must be much less 
energetic than is supposed by those who support the present doctrine, although I 
may grant that it partakes, in some measure, or in some forms of fever, of the 
morbid impression especially and principally made upon the nervous system of 
organic life, and extended to the organs which it actuates." 

" That the efficient agents of fever act primarily and chiefly upon the organic or 
ganglionic nervous system is evident from what has been now adduced, and is farther 
proved by the following facts and inferences : a. The intimate connection of this 
system with the organs of circulation, respiration, assimilation, and secretion, on 
the one hand, and with the cerebro-spinal nervous system on the other, and the 
influence exerted by it over their functions in health, are sufficient to show that 
morbid impressions made upon it must necessarily affect all the organs and parts 
with which it is related. 6. The functions primarily disordered in fever, and chiefly 
affected in its course, are precisely those which are especially subjected to the 
influence of this system. As we cannot, consistently with our knowledge of the 
animal actions in health and in disease, infer that a grave and permanent disorder 
of any one function can exist, unless either the influence that actuates it is 
impaired, excited, or otherwise altered, or the structure of the organ, which is the 
instrument of the function, is more or less affected ; we are necessarily led to 



156 



OBSEEVATIONS ON 



Still a fourth theory may be advanced to account for the changes; 
that the poison or poisons acted primarily upon one or both the 
grand portions of the nervous systems, and the cerebro-spinal and 
sympathetic systems, singly or combined, in turn altered the ac- 
tions of the organs and apparatus, and the secretions and excre- 
tions, and chemical and physical actions over which they presided. 

We will discuss these questions more fully hereafter, when we 
consider the nervous phenomena. 

Before, however, dismissing the subject, we would state that in 
the present state of medical science, we cannot decide dogmatically 
upon the truth of these theories, because the ultimate facts are 
wanting. 

What is the poison or poisons which we have assumed to exist, 
and act upon the organs and tissues, and solids and fluids ? 

What is the relation of these substances, physically, chemically, 
phj^siologically and pathologically to the cerebro-spinal and sym- 
pathetic systems, to the blood-corpuscles and elements of the blood, 
organic and mineral, and to the organs, tissues, and secretions and 
excretions ? 

In other words, what physical, chemical, physiological and pa- 
thological changes, are they capable of producing in the solids and 
fluids of the human body, and what effects would these changes 
have upon the development and action of the vital and nervous 
forces? 

inquire as to wliicli of these sources the disorder is to be imputed. Having 
inferred from the nature and extent of the disorder, from the causes in which it 
arose, and the suddenness and manner of its occurrence, as well as from various 
other circumstances, that it does not consist of lesion of structure, we are, there- 
fore, compelled to adopt the former alternative, and, from the kind of disorder, to 
infer the manner in which the influence actuating the organ is affected. Thus, 
observing that respiration, circulation, secretion, and animal heat are primarily 
and especially disordered at the commencement of fever, and that various other 
morbid phenomena are consequently produced, and finding no structural or local 
change to account for the affection, we refer it to the state of the influence which 
actuates these functions. Anatomical and physiological evidence concur in show- 
ing that the nervous system of organic life is chiefly concerned in the production 
of those functions ; and, therefore, it may be inferred that this system is first 
impressed by the causes of the disease."* 



* A Dictionary of Practical Medicine, comprising General Pathology, tlie Nature and Treatment of 
Diseases, Morbid Structures, and the Disorders especially incident to Climates, to the Sex, and to the 
different Epochs of Life, &c., by James Copland, M. D., F. R. S., &c. Edited with additions by 
Charles A. Lee, A. M., M. D., &c , in three volumes. New York, Harper & Brothers, 1855. Vol. I., 
article Fever, pp. 1064, 1065 ; also pp. 1038-lOSL Intermittent fever, pp. 1085-1100. Remittent fever, 
pp 1100-1122. Hectic, Continued, Inflammatory, Bilo-gastric, Synchoid, Typhoid, and Typhus fevers, 
pp. 1123-1230. Article Disease, pp. 641-689, 



MALAEIAL FEYER. 



157 



Until these questions are definitely answered, our opinions must 
be speculative, and not absolute, and the results of our analogical 
reasoning must be expressed as hypotheses and not as laws. 

The destruction of the colored corpuscles ; the golden color of 
the serum; the slate color of the liver upon the exterior, and 
bronzed color in the interior; the color of the bile; the absence of 
grape-sugar from the structures of the liver; the slate color of the 
spleen, and the disorganized state of its tissues, and the inability of 
its pulp to change from the dark reddish-brown to the arterial 
color, gave decided evidence that this was a case of malarial fever. 

There were, however, other symptoms and other lesions, which 
indicated that there was something besides malarial fever. The 
cerebral and nervous symptoms ; the continued febrile excitement 
without intermission ; the loose state of the bowels ; the unusual 
action of a small dose of castor oil ; the enlarged and congested 
glands of Peyer, and solitary glands of the intestines, indicated 
the presence of typhoid fever. The history of the case (the recent 
attack of remittent fever), and the fact that the glands of Peyer 
showed the marks of recent, only partially developed inflamma- 
tion, and pathological changes, and not the changes produced by 
typhoid fever of long standing, lead us to the conclusion that the 
remittent fever preceded, or was, at least, simultaneous with the 
appearance of the typhoid fever. 

The blood in No. 7 was abstracted from an Irish laborer, who 
had been reduced by an attack of remittent fever, diarrhoea, and 
salivation, from 200 pounds to 100. At the time of this analysis, 
he was suffering with foul ulcers in his mouth, and over the sur- 
face of the body, especially upon the back ; and his body had a 
most disgusting nauseous smell. Complexion sallow and anemic; 
and forces completely worn out with pain and loss of sleep. 

Blood coagulated slowly. In the specific-gravity bottle, the 
colored corpuscles settled to the bottom, leaving above a clear 
golden-yellow clot. 

In a small, shallow porcelain capsule, the superior central por- 
tions of the clot appeared transparent for several lines in depth. 
A portion of the blood was set aside in a glass vessel. In twelve 
hours the clot commenced to disintegrate and liberate its colored 
blood-corpuscles, and in twenty-four hours the blood gave forth a 
putrid smell, and the serum was filled with the liberated colored 
corpuscles presenting the appearance of blood. A specimen of 
blood drawn at the same time from a patient who had recovered 



158 



OBSEEVATIOXS 0:N' 



from an attack of intermittent fever three weeks before, was placed 
in the same room, in a similar bottle, bj the side of this specimen. 
The clot, serum, and odor of this remained unaltered for fifty hours. 

Serum of a golden-yellow color. The colored blood -corpuscles 
were diminished nearly one-half, and the fibrin was slightly in- 
creased. The golden color of the serum, and the foul ulcers, and 
the readiness with which the blood underwent putrefaction, all 
pointed to alterations in the constituents of the blood and nutritive 
fluids. Stimulants, tonics, and alteratives produced but little ap- 
parent effect. 

The patient continued dull, stupid, anxious, distressed, and feeble. 
His body continued to exhale the disgusting stench. 

Four days after bleeding, his left arm swelled enormously. 

Eleven days after the abstraction of the blood, he took a sudden 
and remarkable change for the worse. 

Lay in a stupor, with mouth and eyes open, with every tendon 
and muscle of his body twitching and jumping violently. Respi- 
ration 42, labored, thoracic, spasmodic like that of a man during a 
severe chill. At every inspiration and expiration, emits a sound 
like the hoarse bark of a thirstv and starved dos:. The muscles of 
the face contract and relax, and contort in every possible manner, 
making the most awful grimaces. During these contortions of the 
muscles of the face, every expression of ridicule, sarcasm, joy, pain, 
agony, malice, revenge, and hatred, are depicted in rapid succes- 
sion. The jerking of the muscles appear to be paroxysmal; they 
are very violent for a few moments, and then moderate for a few 
moments. The patients in this large hospital ward, state that they 
were kept awake during the whole night, by his barking and shak- 
ing. Pulse lii, feeble. It was very difficult to count the beats of 
the pulse, on account of the violent twitchings of the tendons of 
the forearm. Temperature of trunk and extremities, several de- 
grees above the normal standard. Skin covered with clammy 
sweat, which resembles bloody serum, and stains his clothes and 
bed just as bloody serum would do. Odor of his body intolerable. 
Passes his feces and urine in bed. This patient continued in this 
condition for three days, and finally died. Unfortunately, no post- 
mortem examination was performed, on account of the earnest en- 
treaties of his superstitious friends. 

This second attack was, in all probability, either a relapse, or a 
fresh attack of malarial fever. 

This case illustrates in a forcible manner the effects of the ma- 



MALARIAL FEVER. 



159 



larial poison in altering the constitution of the blood, and of the 
organs aad tissues, and in causing aberration of the muscular and 
nervous, and physical and vital forces. 

The blood in No. 8 was drawn from the arm of a German butcher, 
who had suffered for two months with chill and fever, without any 
medical attendance, and who entered the hospital in a comatose 
condition, reduced in flesh from 180 pounds to 110 pounds, with 
feeble forces. 

Complexion sallow, anemic; nervous and muscular forces very 
feeble. Pulse 120, feeble. Respiration 24, labored. Tongue per- 
fectly dry, and rough. Skin dry and rough over all parts of the body. 
Although revived and partially relieved by sinapisms, stimulants, 
and sulphate of quinia, the malarial poison had induced such pro- 
found alterations in the blood and organs, that the effects were 
followed by the most distressing suffering, and finally death. 

The blood drawn shortly after his entrance into the hospital, 
whilst he was in this comatose condition, coagulated rather slowly. 
In one specimen, the coagulation was remarkably slow, and the 
blood-corpuscles gravitated towards the bottom of the vessel, and 
left above a clear, golden-colored clot. The transparent portion of 
the clot was about one-fourth of an inch in thickness. Serum of a 
deep golden color, reaction alkaline. 

The fibrin was greatly deficient. The deficiency of the fibrin in 
the blood was further demonstrated by the fact that the blood 
oozed from the cut-cups upon the temples for eighteen hours, and 
it was finally necessary to check the flow by cold affusions. 

The colored blood-corpuscles were greatly diminished; the dried 
corpuscles being 79.434, and the moist corpuscles 317.748. The 
fixed saline constituents were correspondingly reduced in amount. 
The albumen was also diminished. 

It is worthy of note that, in the different forms of malarial fever, 
the serum is alkaline, whilst the saliva and urine are intensely 
acid. 

The following table will illustrate the prominent symptoms : — 



160 



OBSERVATIONS ON 



Date. 



1857. 



Hour 

OF DAT. 



State of Skin, Tongue, Intellect, &c. 



Sept. 28 



29 



7 P. 
11 A. 

7 P. 
21 p. 

2 P. 

2 P. 



2i P. 
2 P. 



2 P. 
4 P. 



M. 



M. 



4 P. M 



4 P. 
4 P. 



Lies in a stupor ; tongue dry and rough ; skin dry 
and rough. 

Intellect brighter, but still very dull ; tongue slightly 
coated with yellow fur and dry. 

Pulse very feeble, feels like the vibrations of a deli- 
cate silver thread ; tongue and skin dry and rough. 

Tongue moister and softer; surface of blister red, 
•aw, and dry ; urine bright red, sp. gr. 1016. 

Restless and stupid ; tongue dry and rough ; teeth 
coated with sordes. 

Intellect more active, but still dull ; patient has a 
disagreeable smell ; tongue coated with brownish- 
yellow fur, and harsh, dry, and rough ; the inci- 
sion in the arm where he was bled has not healed, 
limpid serum issues from it ; side of head swollen 
and painful. 

Tongue moist and soft; arm in which he was bled 
greatly swollen, veins of surface filled with blood 
swelling of ann due to pressure. 

Swelling of arm and upon left side of face continues 
to increase ; blister purplish red, with dry raw 
surface ; boils and ulcers are appearing upon dif- 
ferent parts of the body ; tongue red, dry, and 
glazed at tip ; root covered with brownish-yellow 
fur. 

Swelling of arm stationary ; swelling upon side of 
face continues to increase. 

Skin hot and dry ; complains greatly of his head 
carotid arteries throbbing violently ; since the 
commencement of the inflammation, the pulse has 
been fuller and stronger. 

When the arm is bent, much serum issues from the 
lancet wound ; surface of blister red and raw, and 
shows no disposition to heal. 

Abscess upon side of head has been lanced ; it dis- 
charged much pus. 

Skin hot and dry ; tongue dry and rough ; abscess in 
angle of jaw continues to discharge much pus and 
masses of cellular tissue ; arm looks badly ; skin 
of arm greenish yellow. 

Surface of blister has commenced to suppurate, and 
discharges unhealthy offensive pus ; the ulcers 
upon various parts of the body steadily increase 
in size, and, like the blister, discharge offensive 
matter. 

The arm looks dreadfully ; skin over biceps muscle 
black and gangrenous ; bowels loose ; digestion 
bad. 

The skin over the entire region of the biceps has 

sloughed away, and left the red quivering muscles ; 

no hemorrhage ; body emits a disgusting stench. 
Continues to grow worse ; impossible to give any 

idea of his distressing, offensive, and disgusting 

situation ! 
Died October 22d. 



120 24 
112 18 



24 



76 



70 



95.12° 



91.00 
88.05 



94.5° 



100 00 
101.00 



102.00 



103.75 



104.0 



104.5 



In tlais report of the symptoms of this patient, we have a demon- 
stration of the powerful effects of the malarial poison when un- 
checked. We see that a few days after his entrance into the hos- 
pital, a large abscess formed upon the side of his head, in the region 
of the ear, and joint and angle of the inferior maxillary bone. 
Notwithstanding that this abscess was lanced, the pus formed an 
entrance into the external meatus auditorius. Large masses of 
cellular tissue and muscles sloughed away, and the angle and supe- 



MALARIAL FEVER. 



161 



rior portion of the inferior maxillary bone were almost completely 
stripped of flesh. The abscess compelled him to lie upon the 
opposite side of his body, and finally the skin over the biceps 
muscle changed to a black color, and sloughed off in a single night, 
leaving the red quivering muscles entirely exposed. The biceps 
muscle sloughed entirely off from its lower attachment. 

After death, his liver presented a color a shade lighter than the 
slate color of the malarial fever liver, and in many parts it was 
regaining its normal hue. Spleen enlarged; surface covered with 
effused coagulable lymph, and bound to the liver and diaphragm 
by bands of coagulable lymph. A large quantity of pus of a 
greenish-yellow color issued from the anterior border of the spleen. 
Whether the abscess had opened and discharged this pus before 
death, or whether the abscess was accidentally ruptured during the 
opening of the chest and abdomen, I was unable to determine. 
The structure of the spleen felt firm, and very unlike the soft, 
yielding structure of the spleen of the active stages of malarial 
fever. When cut, many portions of the spleen resembled the cut 
surface of a dark, bronzed malarial liver. The pulp of these por- 
tions was not soft, and did not pour out like the pulp of the spleen 
of the active stages of malarial fever. The liver-like substance of 
the spleen was found to consist, under the microscope, of fibrous 
tissue and numerous colored corpuscles and flakes, composed of 
granules resembling the dark-colored flakes of black- vomit. These 
flakes were, without doubt, composed of altered colored corpuscles. 
The colorless corpuscles of this portion of the spleen appeared to 
be more numerous than normal. This dark liver-like substance 
appears to be nothing more than the pulp and effused blood of the 
spleen, from which the serum has in a great measure been removed, 
and in which alterations of the blood-corpuscles have taken place, 
and fibrous tissue formed. After many hours' exposure to the 
oxygen of the atmosphere, the color of this portion of the spleen 
remained unchanged. 

In addition to the abscess opening upon the surface of the spleen 
attached to the liver, the substance of the spleen contained numerous 
other abscesses of various sizes (the three largest were of the size 
of a bullet, and the smallest of the size of an English pea), filled 
with thick greenish-yellow pus. Portions of the spleen especially 
surrounding the abscesses, were altered into a cheese-like substance. 
Under the microscope, these cheese-like portions consisted almost 



162 



OBSEEVATIONS OK 



entirely of pus corpuscles and large cells, containing granules and 
other smaller cells, thus resembling cancer-cells ; and also black 
masses composed of granules (probably altered colored corpuscles), 
like those from the denser portions of the spleen ; and also nume- 
rous oil-globules. The bodies resembling cancer-cells were not 
numerous. The pus issuing from the large abscess resembled ordi- 
nary pus under the microscope, and contained a few of those pecu- 
liar cancer-like cells. 

The bile presented a brownish-yellow opaque color when seen in 
mass, and a gamboge-yellow in thin layers. The bile contained 
numerous irregularly-shaped yellow masses of various sizes, from 
an English pea to a grain of sand. These yellow masses, which 
were soft and readily crushed between the fingers, formed about 
two-fifths of the contents of the gall-bladder, and were found, under 
tbe microscope, to consist of numerous cells from the raucous mem- 
brane of the gall-bladder, and a yellow amorphous matter. The 
cystic duct appeared to be choked up with these cells and this 
yellow matter. 

The stomach, and small and large intestines were greatly con- 
tracted. The mucous membrane of the stomach presented an ap- 
pearance resembling that of chronic inflammation. The exterior 
of the large and small intestines was of a purplish color. The 
mucous membrane did not appear to the naked eye to be altered 
in structure. The glands of Peyer were enlarged and distinct; 
some of them were several inches in length. They were paler than 
usual, and did not present the appearance of active inflammation. 
The lymphatics of the mesentery were much enlarged. 

This case demonstrates that the action of the malarial poison is 
chiefly through the sympathetic nervous system, and that its eSects, 
even after the direct action is checked, result in a further perver- 
sion of the blood, and organs, and tissues. Whilst the cerebro- 
spinal nervous system had recovered in a great measure from the 
effects of the poison, and sensation, and motion, and intelligence 
were restored, the pathological alterations of the spleen and aliment- 
ary canal, and of the liver and blood, continued. 

Many, if not all, the nervous affections and neuralgias occurring 
after attacks of malarial fever, or after the long-continued action of 
the malarial poison, in miasmatical situations, are connected with 
the altered state of the blood, and organs, and secretions. 

Alterations of the solids, similar to the one just recorded, have 
been observed by Dr. Samuel Jackson, of Northumberland, Pa. 



MALAEIAL FEVEK. 



163 



The following cases of gangra3nopsis, or gangrenous erosion of 
the cheek, following malarial fever, are quoted from his interesting 
article, published thirty-two years ago, in the American Medical 
Recorder: — 

"Case 1. Mary, aged six years, daughter of John Eisely, of Sun- 
bury, was seized, in September, 1822, with an epidemic remittent 
fever, w^hich, in a few days, and before they obtained medical aid, 
had resolved itself into the intermittent form. I was called about 
the tenth day of her disease, when one side of her face was greatly 
swelled, pale, and shining; eyelids of the same side so oedematous 
as to close the eye entirely; lips, and particularly the upper one, 
tumefied ; saliva streaming from her mouth ; breath highly offen- 
sive. 

My first impression was that she was affected with mercury; but 
they assured me, as indeed they always did afterwards, that she 
had taken no other medicine than the common purging salts, which 
they had given without medical advice. 

Upon opening the mouth, I found on the inside of the tumefied 
cheek a patch of gangrene, about as large as a crown piece, and 
without anything like a line of separation. It exhibited a singular 
ash color, approaching to whiteness; but it was plainly the sub- 
stance of the cheek, which was dead and disorganized to a consider- 
able depth. The teeth were all fast, the gums sound and not the 
least sore on pressure, nor did her breath smell precisely like that 
of a salivated patient. This affection had begun two or three days 
before, and had been steadily increasing. The disease was totally 
unknown to me; but the mere indications of cure were not sup- 
posed to be at all mysterious, though I am far from certain of 
havinor fallen on the most successful means of fulfillinsr them. 

An epispastic was applied to the cheek ; the mouth was very 
frequently washed with a succession of gargles, strong alum-water, 
Huxham's tinct., diluted muriat. acid ; and bark, wine, elixir vit., 
and tonic diet were given as freely as the patient could bear them. 
The intermittent was checked at once, and the patient's health 
began to improve before the swelling of the cheek subsided in the 
least, or any line of separation could be seen. The tonic medicines 
and diet were continued, and another blister draw^n as soon as the 
first healed. 

But the state of the cheek meliorated slowly, and I was particu- 
larly struck with the obstinacy of the swelling, and the inability of 



16i 



OBSEEVATIONS ON 



the system to form a line of separation. At the 20th day from the 
time I was called the slough came away, leaving a healthy ulcer, 
which had nearly penetrated the cheek. The teeth and gums were 
not the least affected at any period of the disease. 

Case 2. About the same time, George Gaus, of Sunbury, called 
me to visit his family, three of whom were ill of intermittent fever 
and dysentery. 

His daughter, about four or five years old, had also the cheek 
disease, precisely similar to that of the above child, unless that 
there was very little, if any discharge of saliva. 

The father assured me that she had not taken one particle of 
mercury in any form ; nor can I possibly believe that either he or 
Eisely deceived fne, or that they were deceived themselves; nor, 
indeed, ought this cause of itself to have excited any inquiries con- 
cerning this mineral, since it was not attended with any flow of 
saliva; and, moreover, as in the above case, the teeth and gums 
were in a healthy state. Her dysentery was cured with large doses 
of calomel, jalap, and other purgatives; and at the same time a 
sufficient quantity of bark was given to check the fever. During 
this time, probably, not less than a hundred and fifty grains of 
calomel were given, notwithstanding the state of the cheek. 

For the gangrene she was treated precisely as Eisely's daughter. 
She soon recovered her health, but with a frightful ulcer, which, 
however, did not quite penetrate the cheek. 

How the ulcers in these two cases healed I know not, as I was 
soon taken with the epidemic myself, and confined for several 
weeks. I went to see these patients since writing the above ; 
Eisely's daughter is dead; but the other is a blooming girl, without 
the least deformity. It is not probable that these sphacelations 
could have been arrested without medical aid, though it must be 
confessed that their character appeared to be rather indolent and 
obstinate, than inflammatory and phagedenic. They gave me no 
uneasiness at the time, but subsequent experience has convinced 
me that had the debilitation of the primary diseases proceeded a 
few days longer, the patients might have been brought into the 
utmost danger. 

Case 3. This occurred September, 1823, in a child of Hannah 
Smith, of Korthumberland. 

He was a robust boy of three 3^ears old, who had been taken 
with epidemic remittent fever, for which he was treated with vene- 



MALAEIAL FEVER. 



165 



section, cathartics, antimonials, cold water to the head, and probably 
with something more that I cannot now recollect. He appeared to 
be going on well till the tenth day, when he was taken with an 
incessant agitation of all his limbs, his brain and mind at the same 
time apparently quite unaffected. An epispastic was applied to 
each limb, and nauseating doses of tartar emetic, conjoined with 
laudanum, were given every hour, with the hope of obtaining both 
an antispasmodic and diaphoretic effect ; the exact dose 1 do not 
recollect. 

This troublesome symptom subsided in about forty-eight hours, 
when the dreadful disease of which we are treating was observed 
in the cheek. Its prima fades is so peculiar that we recognized it 
in one moment as the same disease we had seen before in the two 
preceding cases; a swelling and hardness of one cheek, with the 
upper lip slightly tumid, led us at once to suspect the existence of 
mischief within ; nor were we disappointed. A little cineritious 
spot, or rather tumor, was seen behind the opening of the Stenonian 
duct, without any symptom of inflammation near it, or in any part 
of the mouth. As we were alive to the operations of mercury, it 
was not a little gratifying to find the teeth and gums apparently 
quite sound, and not the least sore on pressure; and also that the 
saliva was not increased, nor the breath offensive. 

The fever continued, and therefore general tonics were not admis- 
sible. A blister was drawn on the cheek, and the mouth washed 
frequently with a strong solution of alum. At this time the swell- 
ing was very moderate, and the mortification confined to a point. 
But the face swelled rapidly on that side, and the gangrene pro- 
ceeded without giving any hopes of a line of separation. 

In two days, the pulse became soft and slow, and, the fever being 
now arrested, we forthwith used tonic diet, bark, and elixir vit., 
with the bark poultice to the face. The mouth was washed alter- 
nately with Huxham's tincture and muriatic acid, diluted with four 
times its weight of water, and the sphacelated part was circumscribed 
twice a day with the nitrate of mercury, according to the plan of 
Mr. Kirkland, until it was fairly ascertained to be utterly useless. 
The disease continued its deadly progress till the poor child was 
relieved of life, about the twenty-fifth day of the gangrene. 

During all this time, he suffered very little, if any, pain, and he 
had a ravenous appetite till the last two or three days, though much 
poisonous matter must have been continually passing into the sto- 



166 



OBSERVATIONS ON 



mach. In fact, we were greatly surprised to find him living so 
long, when we consider the deleterious effects of mortification on 
the general system; which, in this case, we did nothing to counter- 
act, after we found it impossible to preserve a tolerable visage. 

One side of this poor child's face was literally destroyed as high 
as the frontal sinus; the teeth, maxillary, malar, palate, nasal, and 
orbitar bones were cast off or were picked away by the patient. 
One whole side of the face, including the mouth, chin, nose, and 
one eye were eaten away — a horrible sight, which even to name is 
a revolting duty. Yet, even in this deplorable state of things, many 
parts of the face put on signs of healing, and, as the patient had a 
good appetite, we felt no little alarm lest he might continue to live 
in this deplorable condition. 

This child had taken some purges of calomel, jalap, and scam- 
mony, in composition, all which operated freely. The breath was 
not that of a salivated patient ; there was no flow of saliva, as in 
the first case, nor did he take any calomel which was not combined 
with the above mentioned active cathartics. 

We gave him large doses of laudanum, in order that he might 
sleep away in comfort the remainder of his life, and that the mother 
might attend to the rest of her family, all of whom were sick ; and 
it is a little surprising that, towards the last, he would take more 
than half an ounce in twenty-four hours, without procuring more 
than ordinary sleep. 

Case 4. In August, 1825, we saw a case exactly similar to this 
in the town of Milton, twelve miles above us. It was in a boy four 
or five years old, the son of one Miller, who still resides in that 
borough. 

The patient had been treated for bilious fever, and had, like the 
little Smith, taken purges containing calomel; and like him, too, 
nearly the whole face was eaten away, after the sphacelation had 
lasted several weeks. TVe believe that no calomel was given which 
had not been combined with more active cathartics ; bat we have 
no means of getting at the exact history of the case. 

Case 5. This was the next that came under my own care, and, 
horrihile dictu^ it was in my own child. 

This little girl, less than two years old, was debilitated by a 
variety of diseases in too rapid succession; an attack of habitual 
intermittent, cjmanche tonsillaris, measles, inflammation of the 
lungs, influenza, and finally her intermittent again; all which con- 



MALAEIAL FEVER. 



167 



fined her about ten weeks, and had nearly brought her to the 
grave. 

When she was in a state of extreme weakness, we observed one 
side of her face a little swelled. I recognized the tumor at once, 
and heard, with the utmost dismay, the little sufferer say, 'Cheek, 
cheek!' while at the same time she put her hand to the affected 
part. On opening her mouth, I found the characteristic gangrene ; 
but it was not larger than a dime piece, and was nearly circum- 
scribed with a healthy periphery. Her catenation of maladies hav- 
ing ended in her old intermittent, we were ready to give quinine 
and tonic diet. 

This case was attended with an odor of the breath altogether 
peculiar and indescribable. Only one dose of calomel had been 
given as a purge, and there was no affection whatever of the teeth 
and gums, nor any flow of saliva." 

Dr. Samuel Jackson gives other cases of this remarkable affec- 
tion, and proves that the affection was not due to the action of 
mercury. 

"That rule of philosophizing, therefore, which refers the same 
phenomena to the same cause, excludes calomel as a direct agent 
in gangrsenopsis. 

All the cases that we have seen were preceded by bilious fever, 
a disease that generally has a tendency to spend its violence in 
some particular part ; and, therefore, if any irritation, and particu- 
larly one that debilitates, should attract and fix the morbific influ- 
ence, a mortification may be the consequence. 

In one case of this fever, we knew blisters to mortify, and in 
several instances we have known a lingering sphacelation of the 
soft parts covering the lumbar vertebrae. 

Upon this principle, then, can mercury have an indirect agency 
in the gangrgenopsis ? 

It is well known that children cannot be easily salivated; but it 
is not reasonable to suppose that mercury has, even in them, its 
specific tendency to the jaws; and, if so, may it not predispose these 
parts to this fatal gangrene, and create that morbific attraction that 
brings upon them the whole weight of general disease? Pars 
dolens trahit is a maxim in medicine as true as any of the Newtonian 
Principia, and is of wonderful efficacy in explaining the mysteries 
of morbid catenations. 

For our own part, we believe that mercury has no direct agency 



168 



OBSERVATIONS OJT 



in gangraenopsis. It may possibly irritate and predispose the part, 
and thus establish a catenation of morbid attraction, and so may 
any other local and debilitating irritation. Upon this principle, 
we have supposed that the disease may arise from any injury done 
to the part, while the system is pervaded by a sphacelating influ- 
ence, as no doubt it is in many cases of fever."^ 

The blood in No. 9 was abstracted from a young American sea- 
man — aged 21 years — with a moderately well- developed muscular 
system, who had been exposed to the malarious influence in the 
Savannah Eiver, when sleeping on the deck of the ship in the 
open air. The ship was lying along the low marshy shore below 
the city. This patient was brought into the hospital in a comatose 
condition, with rapid, feeble pulse, and rapid respiration, with no 
corresponding elevation of temperature. This patient lay in this 
comatose condition, passing his urine and feces for several days, 
until aroused by cut-cups, sinapisms, stimulants, and sulphate of 
quinia. 

The blood was obtained, v^^hilst he was in this condition, three 
days after his entrance into the hospital, and six days after the 
commencment of the attack. 

Blood coagulated more slowly than usual. 

Serum of a deep golden color. Kitric acid showed that this color 
was due to the presence of bile. Reaction of serum alkaline. 

The colored blood-corpuscles were greatly diminished; the dried 
corpuscles being 85.968, and the moist 343.872, in 1000 parts of 
blood. The fixed saline constituents of the colored blood-corpus- 
cles were greatly diminished in amount, whilst those of the liquor 
sanguinis were increased. 

The fibrin was diminished in amount. 

The following table will present a condensed view of the promi- 
nent symptoms: — 

' On the Grangrsenopsis, or Gangrenous Erosion of the Cheek," hy Samuel 
Jackson, M. D., of Northumberland, Pa. American Medical Recorder, 1827, vol. 
xii. pp. 66-96. 



MALARIAL FEVER. 



169 



Date. 
1857. 



Oct. 1 



Hour 

OF DAY 



7 P. M. 



11 A. M. 



7i P. M. 



2 P. M. 



1 P. M. 



1 P. M. 



1 P. M. 



2 P. M. 



1 P. M 



3 P. M. 



2i P. 
2 P. 



State of Skin, Tongue, Intellect, &c. 



Tongue dryer than normal ; coated with 
yellow fur ; complexion sallow ; has fe 
ver, is very weak and dull. 

Comatose; passes urine and excrements 
in bed. 

Restored to the temporary and partial use 
of his intellect by a blister. 

The action of the blister has been only tem 
porary ; pulse is so feeble that it is with 
difficulty counted ; tongue coated with 
yellow fur, dry and rough. 

Lies in a stupor, with mouth and eyes 
partially open ; teeth coated with sordes 
tongue coated with black and light yellow 
fur, perfectly dry and rough ; surface of 
blister red and raw. 

Stimulants and sulphate of quinia have 
aroused him, and excited the chemical 
changes ; is still very weak, and has a 
great tendency to sleep ; skin of head and 
trunk feels a little warmer than normal, 
and is slightly moist ; tongue presents the 
same dry, coated, rough appearance ; re- 
action of saliva decidedly acid. 

Intellect clear, and there is less tendency 
to sleep ; tongue is still very dry, rough, 
and black in the centre ; it appears, how- 
ever, softer; reaction of saliva decidedly 
acid. 

Tongue moister, softer, and cleaner ; says 
that he feels better, and is hungry ; com- 
plexion sallow, anemic. 

The expression of countenance is better, 
and the surface of the blister looks much 
better ; tongue still coated with dark- 
brown fur, but moister and softer ; the 
sordes around the teeth and the disagree- 
able smell are rapidly disappearing ; ab- 
domen tumid ; was able to walk across 
the ward. 

Has taken a change for the worse ; inclined 
to stupor ; goes to sleep whilst convers- 
ing ; countenance anxious and distressed ; 
bowels costive ; during the last four days, 
has taken 100 grs. of sulphate of quinia. 

Anxious expression of countenance ; bow- 
els costive ; abdomen tumid ; tongue a 
little softer and cleaner, but still much 
dryer, harder, and rougher than normal; 
there is still an almost complete cessation 
of the secretions of the mouth. 

Tongue clean, and much moister and soft- 
er; the moisture, however, varies greatly; 
pulse very weak, feels like the vibrations 
of a spider's thread ; greatly exhausted 
by the action of a purgative administered 
the night before. 

Under the action of stimulants has im- 
proved, and looks better ; tongue softer 
and moister than it has been during his 
sickness ; pulse stronger, but still watery 
and feeble. 

Complains of great weakness ; pulse feeble 
and watery ; bowels inactive and tumid. 

Complains of great weakness; his sallow 
complexion, anemic lips and gums, feeble 
pulse, and feeble forces, demonstrate that 
his feelings are founded upon the effects 
of the malarial poison. Applied large 
mustards to the extremities, and admin- 
istered stimulants ; in 10 minutes after 
the application, the temperature of his 
extremities had risen 6° (from 86° to 92="), 
and his pulse had become much fuller, 
and increased 8 beats (from 92 to 100). In 
half an hour after the application of the 
mustards, the temperature of his extre- 
mities had risen 16° and remained sta- 
tionary. 

Half an hour afterwards, the temperature 
still continued elevated. 



92 



96 



71.0 



77.0 



72.5 
73.0 



73.0 



98.0° 



97.0 



High colored; sp. 
gr. 1016 ; uric 
acid in 1000 p'ts 
0..59. 



98.75 101° 



102.0 



102 5 



97.0 



97.25 
86.0 



92.0 



102.0 



102.0 



102.5 
103.0 



103.0 



103.2 



103.0 



Characters of 
Urine, 



Deep orange co- 
lor; sp.gr. 1016; 
uric acid in 1000 
parts 0.659. 

Orange colored ; 
sp.gr. 1016; uric 
acid in 1000 p'ts 
0.511; deposited 
a heavy light- 
yellow deposit 
after standing. 

Light orange co- 
lor; sp. gr. lOOf); 
uric acid in 1000 
parts 0.238. 

Sp. gr. 1006 ; re- 
action alkaline 
after standing 
21 hours ; uric 
acid in 1000 p'ts 
0.078. 



170 



OBSEKVATIONS ON" 



Date. 
1857. 


Hour 

OF DAY. 


State of Skin, Tongue, Intellect, &c. 


1 Pulse. 


o 
1 

16 
14 


Temperature of 
atmosphere. 


Temperature of 
haud. 


Temperature 
under tongue. 


Characters of 
Urine. 


Oct. 10 

" 10 
u 17 


4 P. M. 


Much better ; temperature of the extremi- 
ties corresponds with that of the trunk. 

Appetite good; tongue moist; convalescent. 
Able to walk about the hospital grounds ; 
reaction of saliva very slightly acid. 


100 
76 


69.5 
67.0 


101 0 
97.25 


102.5 
102.0 


Deep orange co- 
lor; sp. gr. 1014: 
12,168 grs. pass- 
ed in 24 hours, 
containing urea 
209.520 gr., uric 
acid 12.60 grs. 



This case presents many points of exceeding interest, whicli will 
be fully noticed hereafter under the proper heads. It illustrates in 
a striking manner, the effects of the malarial poison in producing 
profound alterations in the blood and secretions, and demonstrates 
that such changes are attended by aberrated nervous and physical 
phenomena. 

Throughout this case there was a want of correspondence be- 
tween the temperature of the trunk and extremities. The tempe- 
rature of the extremities was often several degrees below the normal 
standard, whilst the temperature of the trunk was several degrees 
above the standard of health. Accompanying this loss of animal 
heat in the extremities, and exaltation in the trunk, there was 
rapid, feeble pulse, normal respiration, dry, harsh skin, dry mouth, 
feeble digestion, torpid bowels, sluggish intellect and feeble forces. 
These facts, taken in connection with the analysis of the blood, 
show that the malarial poison has produced profound alterations in 
the constituents of the blood, interfered with the formation of the 
secretions, interfered with the chemical changes of the blood and 
nutritive fluids, interfered with the development and correlation of 
the physical, vital, and nervous forces. The dry, harsh tongue, the 
scanty acid secretions of the mucous membrane of the mouth, the 
torpor of the bowels, the high colored acid urine, the dry, harsh 
skin, the feeble circulation in the capillaries of the extremities, the 
elevation of the temperature of the trunk, the loss of harmony be- 
tween the actions of the circulatory and respiratory system, all 
point to profound disturbances in the domain over which the sym- 
pathetic system presides. The sluggish intellect indicated derange- 
ment of the cerebro-spinal system. The feeble forces point to de- 
rangements in both the sympathetic and cerebro-spinal systems. A 
careful comparison of the symptoms of this patient with those of 



MALAKIAL FEVER. 



171 



fatal cases, shows that this was a case of such great severity that 
any carelessness or neglect would have been attended by a fatal 
termination. 

Notwithstanding the administration of the most active tonics, 
and of the most nutritious diet, this patient exhibited, for a great 
length of time, the effects of the bilious remittent fever, in his pale, 
sallow, anemic countenance, pale lips and gums, and tottering gate. 

The violent nature of the malarial fever, contracted by sleeping 
in the open air in the low marshy land bordering our fresh water 
rivers, is forcibly illustrated by the subsequent history of the crew 
to which this patient belonged. 

I was informed, upon reliable authority, that one week after 
the admission of this patient into the hospital, his captain weighed 
anchor and sailed for New York. The crew consisted of the men 
whom he had compelled to sleep on board the vessel lying along 
the low, marshy shore. Several of the crew were unwell at the 
time of sailing. Before getting well out to sea, the captain and the 
whole crew were taken sick. In a few days, there was not a man 
with strength to navigate the ship. Fortunately, a small vessel 
perceived their signal of distress, and towed them into Darien. 
Before reaching this port, the captain and five out of seven of the 
crew, had died. There were but two remaining of eight, and these 
were extremely ill. The severity of the disease, in this case, re- 
sembles the accounts of African fever. 

We will now, from these observations and others, present a gene- 
ralized statement of the changes of the blood in malarial fever. 

1. The careful comparisoyi of the table of the changes of the blood in 
malarial fever with the formula of the bloody established by laborious 
investigations^ reveals the fact that the colored blood- corpuscles are di- 
minished during malarial fever. 

2. The careful comparison of these analyses with each other ^ reveals 
the fact^ that the extent and rapidity of the diminution of the colored cor- 
puscles^ corresponds to the severity and extent of the disease. 

A short but violent attack of congestive or of remittent fever, 
in its severer forms, will accomplish as great a diminution of the 
colored blood-corpuscles, as a long attack of intermittent fever, or 
the prolonged action of the malarial poison. 

These statements are borne out in the main, by the researches 
of Andral and Gavarret, upon the blood in intermittent fever. If 
their analyses be compared with those just recorded, it will be 
seen that whilst the blood-corpuscles are diminished, the diminu- 



172 



OBSEEVATIONS ON 



tion is less than in the blood of the severe cases recorded by my- 
self. When we consider that the climate was much more healthy, 
and that the fevers examined by Andral and Gavarret were only 
of the intermittent type, and in all probability, much lighter than 
the intermittents of the marshes, swamps, and low-grounds, of the 
southern States, which generate a malaria scarcely less deadly than 
that of Africa, it is evident that the results of the investigations in 
America upon malarial fever, agree with those of Europe. 

The following table presents the results obtained by Andral and 
Gavarret, from the examinations of the blood of six persons suffer- 
ing with intermittent fever : — 









Moist Blood-Corpuscles. 




















Solid 
residue of 
serum of 
1000 parts 
of blood. 


Number of 
case. 


Water in 
1000 parts 
of blood. 


Solid 
residue of 
1000 parts 
of blood. 


Moist blood- 
corpuscles in 
1000 parts of 
blood. 


Water in 
moist blood- 
corpuscles of 
1000 parts of 


Solid residue 

in moist 
blood-corpus- 
cles in 1000 


Fibrin. 








blood. 


p'ts of blood. 






1 




... 


511.6 


383.7 


127.9 


3.7 




2 






441.6 


331.2 


110.4 


3.5 




3 






438.0 


328.5 


109.5 


3.5 




4 






423.2 


317.4 


105.8 


3.4 




5 
6 






420.0 
275.2 


315.0 
206.4 


105.0 
68.8 


3.3 
3.0 




Maxima 


847.9 


221.9 


511.6 


373.7 


127.9 


3.7 


91.0 


Minima 


778.1 


152.1 


275.2 


206.4 


68.8 


3.0 


71.6 


Mean 


. 811.4 


188.6 


417.2 


309.4 


104.3 


3.3 


80.0 



MM. Leonard and Foley, of Algiers, concluded from their exami- 
nations of the blood in intermittent fever, that the proportion of 
globules tends either to remain stationary or to diminish.^ 

MM. Becquerel and Kodier have demonstrated that in that pecu- 
liar condition of the system called marsh cachexia, accompanied by 
a remarkable decoloration of the skin, and not unfrequently by 
dropsy, and produced by the long-continued influence of malaria, 
there is the greatest decrease of both the albumen and the globules. 

The following table presents the analyses of marsh cachexia, 
executed by MM. Becquerel and Eodier. 

^ Pathological Chemistry in its Application to the Practice of Medicine. Trans- 
lated from the French of MM. Becquerel and Rodier, hy S. T. Speer, M. D. London, 
1857, pp. 172-174. 



MALAKIAL FEVER. 



173 



Analysis of 1000 parts of Blood. 




e3 

i3 =3 
si a " g j^; 

S ^ ^ 2 

K S o3 'O 


^ o 

7 g 

^ to P e3'« 


c» a x 

to S t3 




"-1 o <» ^ 

n|ll|: 

^ to B o3 15 


Specific gravity- 
Water ..... 
Moist globules 

Solid matters of moist globules 
Water of moist globules . 
Solid matters of serum . 
Fibrin 


1035.40 
869.34 
268.40 
67.10 
201.30 
61.10 
2.36 


1040.00 
853.75 
407.48 
101.87 
305.61 
41.84 
2.54 


1034.06 
869.71 
269.12 
67.28 
201.84 
59.88 
3.13 


1033.85 
875.67 
224.88 
56.22 
168.66 
63.83 
4.27 


1040.51 
846.31 
338.88 
87.22 
251.66 
62.32 
4.15 


Analysis of 1000 parts of Serum. 


Specific gravity 

Water 

Albumen .... 
Extractive matters and salts . 


1020.37 
936.40 
55.68 
7.92 


1016.40 
953.29 
37.26 
9.45 


1021.61 
930.08 
50.20 
13.72 


1024.15 
926.75 
60.20 
13.05 


1023.56 
922.98 
63.25 
13.77 



The mean composition of the blood in marsh cachexia may be 
represented thus : — 
Analysis of 1000 Parts of Blood (Mean Composition of in five Cases of Marsh 



Cachexia) — 

Specific gravity 1036.76 

Water 962.38 

Moist globules 303.76 

Dried residue of globules . . . ... 75.94 

Water of globules . 227.82 

Solid matters of serum 57.79 

Fibrin 3.39 

Mean Composition of 1000 Parts of the Serum. 

Specific gravity 1021.22 

Water 935.10 

Albumen 53.32 

Extractive matters and salts 11.58 



The following interesting remarks, with reference to the cause 
of the dropsy, are made by MM. Becquerel and Kodier : — 

"The dropsy has been attributed to the mechanical obstacle 
afforded by the enlarged condition of the spleen, so common in 
these cases. We do not deny the possibility of such a sequence ; 
but it is certain that in many instances we fail to discover such an 
amount of splenic enlargement, as would suffice to explain the 
occurrence of an increasing and general anasarca. In only one of 



174 



OBSERVATIONS ON" 



the preceding analyses of the blood in marsh cachexia, did we notice 
a marked degree of splenic enlargement ; it was, how^ever, insuf- 
ficient to account for the serous infiltration present."^ 

We will in the next place compare the changes of the blood in 
malarial fever, and in the state of marsh cachexia produced by the 
continued action of the poison, with the changes of the blood in 
the different forms of dropsy. 

The following tables present a resume of the valuable investiga- 
tions of MM. Becquerel and Eodier: — 



Mecha n ica I Dropsy. 



ANALYSIS OF 1000 PAKTS OP BlOOD. 




S — ' ^ 
<~~ " 


c =? X £ 3 

^ r: — ^ ^ ~ 




- 2 

fcc r ^ ^ 
c: -> 

c i 1 f ^' 

S ~ c § s 

--£ .IT ^ 2 o 
^ -5 S ^ 


Specific gravity 

Water 

Moist globules .... 
Solid matters of moist globules 
Water of moist globules . 
Solid matters of serum 
Fibrin 


1057.01 
802.79 
424.92 
106.23 
318.69 
80.20 
1.78 


1053.45 
810.20 
361.30 
90.30 
270.90 
85.50 
4.00 


1060.75 
828.30 
360.08 
90.02 
270.04 
86.03 
5.55 


1043.56 
842.40 
285.48 
71.37 
214.11 
81.85 
5.38 


Analysis of 1000 parts of Seeum. 


Specific gravity 

Water ..... 

Albumen ..... 
Extractive matters and salts 


1032.51 
900.00 
73.26 
26.74 


1033.00 
894.53 
82.62 
22.85 


1028.73 1 1026.69 
905.83 ! 913.68 
76.74 i 70.60 
17.33 : 15.68 



In the blood of mechanical dropsy we have a decrease of the 
globules ; but the diminution is less than that of the severest forms 
of malarial fever, and in marsh cachexia. 

It is worthy of note that other causes than mechanical operated 
in tw^o of these cases. It is probable that the cancers, and the 
peculiar state of the system favorable to the development of can- 
cers, may have had much to do with the pathological changes of 
the blood. 

These cases, then, are not without objections; nevertheless, the 
objections only place in a still stronger light the profound altera- 
tions of the blood-corpuscles in malarial fever. 

^ Patliological Cbemistrj, p. 172. 



MALAKIAL FEVER. 175 



Acute Dropsy. 



Analysis of 1000 parts of Blood.* 


1 Meaa, 


Maxima. 


Minima. 


Specific gravity .... 

Moist globules ..... 

Dried residue of moist globules 

Water of moist globules . 

Solid matters of serum . 

Fibrin 


1045.84 
830.78 
414.32 
104.58 
309.74 
G1.87 
2.77 


1053.30 

539.52 
134.88 
404.64 
65.62 
4.10 


1037.55 

280.40 
70.10 

210.30 
57.24 
1.25 


Analysis of 1000 parts of Serum. 


Specific gravity .... 

Albumen 

Extractive matters and salts . 


1022.61 
928.47 
58.52 
13.01 


1024.28 

63.18 
17.14 


1020.05 

51.12 
7.74 



"The globules are less liable to decrease than in cachectic dropsy; 
they, nevertheless, fell in one case to 70, and in another to 72. In 
three cases they were above 120 per 1000 ; in three others between 
100 and 120 ; and in five cases between 100 and 110. 

The fibrin underwent a marked diminution in two cases only, 
viz., between 1 and 2 per 1000 ; in six cases it varied from 3 to 6, 
while in three others it rose above 3 per 1000. 

The albumen of the serum was always diminished, and in some 
instances this diminution was considerable ; it ranged from 60 to 
66 in four cases, and from 55 to 60 in six others, while in one case 
it fell as low as 51.02. 

It is almost needless to add, that the specific gravity of both the 
blood and serum was always found to have fallen below the standard 
of health." 

* The above table is drawn up from eleven analyses of the blood ; nine of the 
patients were males and two females. In all, the disease set in rapidly under the 
following circumstances : In one case, it followed a sudden suppression of the 
catamenia from violent emotion ; in a second, it occurred at the fifth month of 
pregnancy, without any appreciable cause ; in a third, it followed an attack of 
scarlatina ; in four other cases, it followed prolonged exposure to cold ; in another, 
it resulted from sleeping on the ground in the open air, during the month of June ; 
lastly, in three cases, the cause was inappreciable. In two of these latter, the 
patients were sufiering from a relapse of the disease. Of these eleven patients, 
none entered the hospital before the fourth, or after the eleventh, day of the dis- 
ease. In six cases, dropsy was the only symptom ; in two, it was accompanied by 
fever ; in two others, there was slight fever ; while in another, there was vomiting, 
coupled with a mild attack of jaundice. 



176 



OBSERVATIONS ON 



From a careful historical analysis and examination of these cases, 
Becquerel and Rodier drew the conclusion that acute dropsy was 
the result of albuminuria following congestion of the kidney. 

"Under the influence of some cause or other, congestion of the 
kidney is produced. The congestion is indicated, along with other 
symptomatic phenomena, by the escape of a certain amount of albu- 
men with the urine ; this, ere long, diminishes the natural propor- 
tion of the albumen of the blood, and the latter condition in its 
turn gives rise to a greater or less degree of dropsy. But the con- 
gestion of the kidney is generally of much shorter duration than 
the modification of the blood, and its consecutive dropsy; it disap- 
pears, therefore, long before these latter phenomena; and if the 
patients are not examined until a certain time after the onset of 
the disease, they alone are observed, the escape of albumen with 
the urine having altogether ceased." 

Now, with reference to the diminution of the blood-corpuscles 
and albumen in malarial fever, we can state positively that it is 
not due to the escape of albumen through the kidneys. I have 
examined specimens of urine in all the various forms and stages 
of malarial fever in many cases ; but never but once detected albu- 
men in the urine, and that was in the case already reported of a 
seaman suffering with remittent and typhoid fevers combined. 
We know that albumen does appear in the urine of typhoid fever; 
so this case forms no exception to the previous statement. 

The diminution of the blood-corpuscles and albumen in malarial 
fever appear to be due to one or both of two causes. Either the 
organs destined to elaborate and prepare the blood-corpuscles and 
albumen do not perform their office with sufficient energy to replace 
the constant destruction, or else the albumen and blood-corpuscles 
are destroyed during the chemical changes of fever, and by the 
catalytic action of the malarial poison. 



MALARIAL FEVER. 177 
Cachectic Dropsies.'*- 



Analysis of 1000 parts of Blood. 




A man aged 60, weakened 
by want, and suffering from 
dropsy not referable to any 
appreciable organic cause. 


A man aged 64, suffering 
privations of every kind, 
and laboring under cachec- 
tic dropsy. 


A woman aged 26, laboring 
under cachectic dropsy, fol- 
lowing chronic diarrhoea. 


A man aged 58, suffering 
from anemia and cachectic 
dropsy, following chronic 
diarrhoea. 


A woman aged 25, suffering 
from anemia, chronic diar- 
rhoea, and cachectic dropsy. 


A man laboring under can- 
cer of the stomach and 
general dropsy, the result 
of cancerous cachexia. 


5 "2 2 

i « ^ 

=2 J 9 

§ X ® § 


p 

0-3 
a .2 

^"1 

|l . 

5 — ' eS 

a 0 2 

=^ =■ s 

10.39.66 
939.85 
306.68 
76.67 
230.01 
60.48 
3.00 


Specific gravity 

Water ..... 

Moist globules 

Solid residue of moist globules 
Water of moist globules 
Solid matters of serum 


10.51.10 
82.5.94 
407.84 
101.96 
305.88 
6 8.. 50 
8 60 


10.31.05 
876.82 
259.84 
64.96 
194.88 
55.04 
3.18 


1043. .55 
864.45 
334.-52 
83.63 
250.89 
49.88 
2.04 


1043.82 
847.28 
363.36 
90.84 
272 52 
59.87 
2.01 


1045.01 
824.55 
414 08 
103.52 
310.56 
68.20 
3.73 


1034.13 
S79..54 
216.80 
54.20 
162.60 
63.83 
2.42 


1041.04 
888.24 
188.00 
47.00 
141.00 
62..50 
2.26 


Analysis of 1000 pakts of Sekum. 


Specific gravity 

Water 

Albumen .... 
Extractive matters and salts 


1025.10 
923.50 
65.43 
11.07 


1020.51 
937.86 
51.30 
10.84 


1027.75 
946.. 55 
45.61 
7.84 


1023.89 
935.13 
53.38 
11.49 


1023..35 
923.63 
64.05 
12.35 


1023.32 
938.09 
60.81 
11.01 


1023.03 
923.00 
61.40 
15.60 


1022 67 
932.65 
11.40 
55.95 



A careful examination and comparison of these results, demon- 
strate that the destruction of the colored blood-corpuscles in the 
severest forms of malarial fever, and in the dropsical anemic con- 
dition called marsh cachexia, produced bj the long-continued action 
of the malarial poison, is greater than in mechanical and acute 
dropsies, and equal to destruction of these important constituents 
of the blood in cachectic dropsies, resulting from repeated losses of 
blood, exhausting discharges from the bowels, long-continued expo- 
sure and privations, hunger and thirst, and from that peculiar state 
of the system sometimes manifested in those suffering from cancers. 

These investigations establish, without the shadow of a doubt, 
the fact that the malarial poison, or the peculiar train of chemical 
changes which it excites, destroys the gland-cells of the blood. 

This fact is further sustained by the greater abundance of iron 
in the urine of malarial fever than in that of health. This increase 
of iron in the urine corresponds to the destruction of the colored 
blood-corpuscles, and the elimination of the products resulting from 
their physical and chemical changes. 

3. Our researches shoio that the fixed saline constituents of the hlood 
corpuscles are often diminished in malarial fever. 



> Becquerel & Rodier's Pathological Chemistry, pp. 167-178. 



178 



OBSERVATIONS ON 



ISTumerous examinations of the urine in different stages of mala- 
rial fever, have convinced me that the proportion of phosphates are 
increased after an attack of malarial fever. If the urine excreted 
during convalescence be set aside for a few hours, it will rapidly 
change from the acid to the alkaline reaction, and a heavy deposit 
of prismatic (most generally) and stellate crystals of triple phos- 
phate, and light-yellow granules, and acicular crystals of urate of 
ammonia, will be thrown down. So abundant are the crystals of 
the phosphates in the urine of convalescence, that if, after standing 
until the reaction is decidedly alkaline, it be held in the sunshine, 
thousands of these crystals of the triple phosphate will be seen, like 
small spangles of silver. It is probable that a portion of these 
phosphates, at least, has been derived from the dead, disintegrated, 
chemically altered, colored blood-corpuscles. 

The bearing of these facts upon pathological and therapeutical 
science, is placed in a clear light by a consideration of the pheno- 
mena and offices of the colored blood-corpuscles. 

The specific gravity of the colored blood-corpuscle varies with 
the quantity of haematin which they contain, and with the state of 
concentration or dilution of its contents. The density of the fluid 
contents will depend upon the character and rapidity of the mutual 
interchanges of the cellular fluid of the blood-corpuscles and the 
surrounding liquor sanguinis. Constant action and reaction are kept 
up between these two great elements of the blood. Each corpuscle 
is a cell, resembling in its nutrition, growth, and general structure 
the active agents in the formation, elaboration, and separation of 
all secretions and excretions. Their cell-walls possess the property 
of separating from the surrounding medium certain organic and 
mineral compounds. If a blood-corpuscle be placed in water, it 
swells up and finally bursts. If it be placed in a solution denser 
than its internal contents, they pass out more rapidly than the 
exterior solution passes in, and the cell-wall swells up. The same 
physical laws of endosmose are at work in the animal economy. 
A mutual action and reaction is incessantly carried on between the 
interior contents of the blood-corpuscles and the exterior liquor 
sanguinis. Whenever water or liquids of low specific gravity are 
introduced into the circulatory system they dilute the serum, and 
immediately there is an endosmose of the less dense fluid into the 
denser contents of the corpuscles. Whenever water is withheld, 
the liquor sanguinis continually loses this element by evaporation 
from the surface of the lungs and skin, and by the action of the 



MALAKIAL FEVER. 



179 



kidneys becomes denser than the contents of the corpuscles, and 
exosmose takes place into the surrounding naedium. The cell-wall 
modifies the physical and chemical properties of every molecule of 
liquor sanguinis that passes through its structure. 

In pathological conditions the cell-wall may be altered in che- 
mical and physical condition. This alteration will necessarily be 
attended by disturbance of the physical and chemical relations of 
the exterior liquor sanguinis to the interior cellular fluid. 

In pathological conditions (as we have just demonstrated in ma- 
larial fever) any one or all the mineral and organic constituents of 
the blood-corpuscles may be altered physically and chemically. 
These alterations will be attended by corresponding alterations in 
the minute actions and reactions of the liquor sanguinis and cellular 
fluid. 

In pathological conditions, any one or all the constituents of the 
liquor sanguinis may be altered, physically and chemically, and 
exist either in deficiency or excess ; or some new constituent may 
be introduced. 

These alterations may interfere with the physical and chemical 
alterations of the blood-corpuscles ; and may even prevent the 
development and nutrition of the blood-corpuscles; may be attended 
by a perversion of all the chemical and physical actions, and final 
death of the blood-corpuscles. 

These views are borne out by the fact, that whilst in healthy 
human blood the density of the blood-corpuscles varies in man 
from 1088.5 to 1088.9, and in woman from 1088.0 to 1088.6, in 
diseases the density is not confined to these limits; for in cholera 
Schmidt found that the specific gravity of the blood-corpuscles was 
increased to 1102.5, or even to 1102.7; whilst in dysentery it was 
diminished to 1085.5, in albuminuria to 1085.5, and in dropsies to 
1081.9. 

Any alteration in the constituents of the Hood corpuscles must 
alone^ independently of any actual destruction^ produce disturbances 
in the muscular and nervous systems. The truth of this assertion 
is evident, when we reflect that one of the most important results 
demonstrated by the researches which we recorded in a former 
chapter, was that th>e development of the muscular and nervous 
systems was always attended by an increase of colored corpuscles 
in the animal kingdom. 

The researches'of C. Schmidt have shown that the fluid contents 
of the blood-corpuscles contain,, in addition to peculiar organic 



180 



OBSERVATIOXS ON" 



matters, a preponderance of the phosphates and potash salts ; whilst 
the liquor sanguinis contains the chloride of sodium in large amount, 
with a little chloride of potassium and phosphate of soda. 

In the blood-cells the fatty acids and globulin are combined both 
Avith potash and soda ; whilst in the plasma the organic materials 
are combined only with soda. 

The researches of Liebig, confirmed by those of Schmidt, have 
shown that the fluid contained in the tubules of muscles is like that 
of the blood-corpuscles, exceedingly rich in the phosphates and pot- 
ash salts. The phosphates also exist in large amount in the brain. 

These facts not only show that the blood-corpuscles may separate 
and elaborate from the liquor sanguinis those organic and inor- 
ganic compounds which constitute the most important part of the 
structures of the muscles and brain, but they also show that altera- 
tion or destruction of the colored corpuscles must be attended by 
aberrated muscular and nervous action. Numerous physiological 
and pathological facts might be brought forward to support these 
views. They not only ihroio light upon many of the phenomena of 
malarial fever ^ especially those connected with the circulatory^ muscular^ 
respiratory^ and nervous systems^ hut they also indicate certain imporiarit 
2)rinciples of treatment. 

(a.) Bloodletting should he avoided, as a generalrule, in malarial fever. 

This principle applies to general, and not local bloodletting. 

I have used local bloodletting (cut cups) in scores of cases of 
malarial fever, and always with apparent benefit. Over the epi- 
gastrium, it often arrests obstinate vomiting, and over the temples 
and back of neck and over the spine, it often relieves distressing 
pain. 

Local differs from general bloodletting in two essential degrees. 

First, the quantity of blood abstracted is much less, and second, 
the number of colored blood-corpuscles is less in proportion to the 
amount of blood abstracted in local, than in general bloodletting. 
The colored blood-corpuscles rush along in the centre of the streams, 
and in general bloodletting they are lost more rapidly than the 
other constituents of the blood. 

The malarial poison, whatever it be, destroys rapidly the 
colored blood-corpuscles. Whatever, therefore, diminishes the 
colored blood-corpuscles, acts in concert with the malarial poison. 

The malarial poison reduces rapidly the forces: 



MALARIAL FEVER. 



181 



General bloodletting reduces rapidly the forces. The two in this 
particular, again act in concert. 

We would not for one moment deny that circumstances may 
arise, when bloodletting would be beneficial in malarial fever. 
AVhenever it is used, it should be borne in mind that it does not, 
and cannot cure the disease. Its beneficial action is only tempo- 
rary, and so far from curing the disease, the relief which it has tem- 
porarily afforded will vanish, if other remedies, especially the sul- 
phate of quinia, be not used, and as a general rule, without these 
remedies, the patient will be in a much worse condition than if the 
bloodletting had not been employed. 

In the use of bloodletting in malarial fever, we should ever re- 
member that the cerebral symptoms, the delirium and the torpor 
of the intellectual faculties, and the congestion of the internal 
organs, are not inflammatory; they are not due to an exaltation of 
the functions, or to an irritation of the congested organs, but rather 
to a loss of power in the circulatory apparatus, heart, arteries, capil- 
laries, and veins, and to disturbances of the physical, chemical, 
and nervous forces. 

The blood stagnates, and accumulates in the capillaries of im- 
portant organs, because the blood has been altered by the malarial 
poison, and the changes which it induces ; because the relations 
between the blood and its containing vessels, especially the capilla- 
ries, have been disturbed; because the regular, normal chemical 
changes necessary for the development of the forces which work 
the machinery, are not generated with sufficient energy, or if gene- 
rated with even increased energy, they are not generated in the 
right position and in the proper quantities, and the correlation of 
the physical, chemical, nervous and vital forces is thus deranged ; 
because the action of the sympathetic nervous system which accom- 
panies the bloodvessels, and regulates the circulation, and respira- 
tion, and secretion, and nutrition, and excretion, and relates them 
to each other and to the cerebro-spinal system, has been disturbed 
by the direct and indirect action of the poison, by the direct action 
of the poison upon the sympathetic and cerebro-spinal nervous sys- 
tems, or by the relations of the chemical changes induced, or the 
products generated in the constituents of the blood, by the malarial 
poison, to the sympathetic and cerebro-spinal nervous systems. 

We will ilustrate these principles of treatment by a single case 
of congestive fever, selected from a multitude, every one substan- 
tiating these statements. 



182 



OBSEKVATIONS ON" 



Case Illustrating the Effects of Bloodletting in Malarial Fever. — 
German, aged 27; height 5 feet 9 inches; weight 160 pounds; 
brown hair, blue eyes, florid complexion; thick-set, stout and mus- 
cular ; thick, short neck ; person filthy ; habits intemperate. 

Last winter and spring he was in the hospital with a large ulcer 
upon the leg. Has been working for three weeks in a mala- 
rious locality, near Lover's Lane, on Thunderbolt road. Has been 
much exposed to the hot sun and cold night air. 

August 21st, 1 o'clock P. M., 1857. Entered the Savannah Hos- 
pital yesterday afternoon, at 4 o'clock P. M. The nurse states that 
during the night he appeared to be out of his head, and would 
frequently start out of bed with a loud shout. Complained bitterly 
of his head. Had two convulsions during the night, one at 12 
P. M., and the other at 2 A. M. 

Now, 1 o'clock P. M., this patient appears to be suffering intense 
agony in his head, and has a hot fever. Both hands are clasped 
around his head, and he tosses violently about in his bed. Every 
breath is accompanied with a deep groan, and an exclamation about 
the pain in his head. He is unable to give a coherent answer. 

Applied immediately four cut-cups to his head (two to back of 
neck, and two to temples) ; also a large mustard plaster over his 
epigastrium, and one to each leg. Abstracted f^xviij of blood in 
the standing posture, until he fell back upon the bed, completely 
exhausted. 

The loss of blood was attended with almost immediate relief of 
the pain in his head. The burning heat of the head and skin was 
almost immediately diminished, and the dry and parched skin was 
soon covered with perspiration. 

The pulse and respiration were diminished in frequency. 

Eespiration, 89 ; pulse, 92. Temperature of atmosphere, 80° F.; 
temp, of hand, 89 ; temp, under tongue, 97. 

The temperature under the tongue is 3°, and the temperature of 
the extremities is 9° below the normal standard. The temperature 
was not ascertained by the thermometer before the abstraction 
of blood, owing to the great suffering and restlessness of the 
patient, but judging by the sense of touch, it is evident that the 
temperature has diminished rapidly since the abstraction of blood. 
The wild and restless glances of his eye, and the violent tossing of 
his body, have ceased, the pain in his head has almost entirely dis- 
appeared, his intellect is calm, and he converses rationally. Tongue 
thickly coated with yellow and black fur, tip and edges clean and of 



MALARIAL FEVER. 



183 



a scarlet color. Previous to the bleeding, the tongue was dry, rough, 
and where the fur was absent, glazed; now it is more moist, but 
still much dryer than normal. 

He is now able to give an account of his case, and states that the 
fever came on three days ago, with a chill, and pain in the head ; 
and that it has continued unabated, up to the present time. Says 
that he took blue pills and oil yesterday morning, before entering 
the hospital, which operated freely. Complains of great thirst. 

R. — Citrate of potassa sj ; bicarbonate of potassa 5j ; water 
f^xxviij. Sig. — Drink ad libitum. 

22d, 12 o'clock M. Head is well. Has not complained of his 
head since the abstraction of blood. Superior portion of tongue 
coated with thick, dry, yellow fur, inclining to black in the centre. 
Tip of tongue clean, bright red, dry and glazed. Complains of an 
unquenchable thirst. Lies quietly. 

Eespiration 52, hurried, labored, thoracic, striking the attention 
of the most casual observer. 

Pulse, 112 ; respiration, 52. Temperature of atmosphere, 81° F.; 
temp, of hand, 99 ; temp, under tongue, 104. 

Skin of trunk feels hot to the hand. Epigastrium very tender 
under pressure. 

B. — Blister six inches by six inches over epigastric region. 
R. — Calomel gr. v; rhubarb gr. viij. Mix. Gruel and flaxseed 
tea. 

23d, 12 o'clock M. Says that his head is much better, and he 
feels perfectly well. 

Blister has drawn ; serum from the blistered surface of a golden 
color. Medicine operated four times; evacuations small. The 
tongue presents the same appearance. Tenderness of epigastrium 
greatly diminished. 

Pulse, 72 ; respiration 34, thoracic, labored. Temperature of 
atmosphere, 78° F.; temp, of hand, 89; temp, under tongue, 96 to 
96.5 ; skin feels cool. 

The temperature under the tongue is 3°, and the temperature of 
the hand 8° below the normal standard. There is great want of 
co-ordination between the circulation, respiration, and chemical 
changes. R. — Calomel gr. xij ; James' powder (pulvis antimonii 
compositus) gr. xxij. Mix and divide into six powders, and ad- 
minister one powder every three hours, in a tablespoonful of snake- 
root tea. Sponge skin with salt dissolved in dilute alcohol. Diet, 
gruel and gum-water. 



184 



OBSERVATION'S ON 



24tli, 9^ o'clock A. M. The nurse states that he has been rest- 
less during the night, and apparently out of his head. Several 
times he sprang out of the bed with a loud shout. At one 
time he insisted that he was perfectly well, and affirmed that he 
was going down to the hotel to get a cup of coffee, some boiled 
eggs, and a good drink of brandy. Now, his respiration is spas- 
modic, 40 to the minute. Pulse cannot be felt. Have administered 
brandy, but he is unable to swallow, or to articulate. He died fifteen 
minutes after this observation. His death struggles were severe 
and distressing. Deep and violent inspirations and expirations ; 
mouth filled with froth which was scattered in every direction, with 
the violent expirations. 

The examination of the body four hours after death, demon- 
strated, that whilst the blood was congested, stagnated in the capil- 
laries and veins of the brain, and lower dependent portions of the 
lungs and skin, and organs, and muscles generally, and of the in- 
testines, there were no marks of inflammation. 

The slate-colored liver ; the dark greenish-brown bile ; the ab- 
sence of grape sugar, and the presence of animal starch in the liver; 
the slate-colored, enlarged, engorged, softened, spleen; demonstrated 
that this was a case of malarial fever; the rapid, feeble pulse; rapid, 
labored respiration ; and depressed temperature of the trunk and 
extremities, marked this case, as belonging to that type of malarial 
fever called congestive fever. 

After the abstraction of blood, there was no correspondence be- 
tween the circulation, respiration, and chemical changes. Before 
the abstraction of blood, there was a rapid pulse ; rapid, full, tho- 
racic, labored respiration, and dry, hot skin, and dry, red tongue, 
accompanied by violent pain in the head. After the abstraction 
of blood, and the application of mustards, there was a slight reduc- 
tion of the temperature of the trunk and extremities ; the tempera- 
ture of the extremities was reduced 9° below that of health ; the 
pain in the head vanished ; the tongue became a little more moist, 
but none the less red. 

To a casual observer, the disease would appear, in a great mea- 
sure, to have been conquered by the abstraction of blood ; the 
symptoms, however, were only moderated. The congested blood- 
vessels of the brain were relieved, and the pain arising from the 
chemical changes, and stagnation, and engorgement of the altered 
blood in the bloodvessels and capillaries of this delicate organ, was 
correspondingly diminished. The temperature of the trunk rose 



MALARIAL FEVER. 



185 



5° above the normal standard, on the next day, whilst that of the 
extremities just reached the normal standard. This increase was 
attended by a far greater acceleration of the respiration and circu- 
lation than was necessary in health, to produce this increased 
chemical change. We shall show, in a subsequent chapter, that if 
the functions of the organs and apparatus be properly performed, 
a full, rapid and vigorous circulation and respiration, must be 
attended by the rapid absorption and distribution of oxygen, and 
corresponding rapid chemical changes. 

In this case we had the rapid circulation and respiration, but a 
deficiency of corresponding chemical change, and hence conclude 
that the malarial poison has acted, either by inducing directly such 
changes in the blood as to prevent its absorption of oxygen, or to 
prevent the rapid action of the oxygen absorbed, or by interfering 
with the metamorphoses of the solids and fluids of the organs, and 
tissues, and nutritive fluids, or by a direct action upon the struc- 
tures or nerves of the heart, thus deranging the circulation of the 
blood, and through it all the chemical changes of nutrition, secre- 
tion, excretion, and the development of the forces, or by a direct 
action upon the nervous centres of the sympathetic nervous system, 
which preside over and relate to the circulation and respiration, and 
through them the chemical changes in the lungs, and heart, and 
bloodvessels, and capillaries, and organs, and tissues, and cerebro- 
spinal nervous system. 

The rapid but feeble action of the heart ; the rapid but feeble 
pulse ; the depressed temperature of the trunk and extremities ; 
the dry red tongue ; the acid, light-colored urine ; the feeble gene- 
ral and capillary circulation gradually overcome by the action of 
gravity; the gradual settling of the blood previous to death in the 
bloodvessels of the most dependent parts of all the organs and 
tissues; the alterations of the blood-corpuscles of the liver and 
spleen; the alterations in the color and constitution of the bile; 
the destruction of the special ferment in the blood which converts 
the animal starch into grape-sugar ; demonstrated that the malarial 
poison had acted chiefly upon the sympathetic nervous system, and 
produced profound alterations in the structure of the nutritive 
fluids, and correspondingly interfered with the chemical changes, 
the development of the forces, and the formation of the secretions 
and excretions. 

The theory then suggested, and most strongly supported by the 
case, is, that the malarial poison acted primarily and simultaneously 
13 



1S6 



OBSERYATIOXS ON 



upon the blood, and spleen, and liver, and sympathetic nervous 
system, and secondarily upon the cerebro-spinal nervous system. 
We shall show presently that the blood in fevers is altered before 
the manifestation of aberrated cerebro-spinal nervous action. The 
same thing may be established with reference to the organs. T\"e 
shall also show that the symptoms and aberrated phenomena mani- 
fested by the sympathetic nervous system precede those of the 
cerebro-spinal sj-stem. Nevertheless, in the present state of medical 
science ; whilst we are ignorant of the chemical and physical pro- 
perties and relations of the malarial poison ; whilst we are unable 
to observe the first aberrations of sympathetic and cerebro-spinal 
nervous phenomena, manifested either in an excess or deficiency 
of secretion, and nutrition, and chemical change, or in a disturb- 
ance of the mutual relations of the two systems to each other, and 
to the respiration and circulation, and to the organs and tissues ; 
the interests and extent of science forbid the dogmatic location of 
the origin of malarial fever in one system of nerves or the other, 
or in both, exclusive of the blood, or in the blood and organs 
exclusive of the two nervous systems. 

The treatment of this case was radically defective. The blood- 
letting Avas proper as a means of relieving the brain, but not as a 
remedy applied alone, to combat the action of the malarial poison. 
The bloodletting relieved the brain, but the poison went on acting, 
altering the chemical relations of the elements of the blood, and 
liver, and spleen, more rapidly than ever. Here we have the cere- 
bro-spinal difficulty apparently relieved ; whilst the war is raging 
in the domain over which the sympathetic system is said especially 
to preside. There was a calm, but it was the calm of conquest ; 
the calm of exhausted nature. The mighty foe carried forward 
the work of destruction without noise or confusion, because all 
opposition was levelled, all resistance subdued. This state of things 
demanded prompt and vigorous action on the part of the physician. 
Those remedies should have been administered which would have 
aroused the capillary circulation ; aroused the sympathetic and 
cerebro-spinal nervous systems, and accelerated the absorption, and 
distribution, and action of oxygen, and the chemical changes of the 
nutritive fluids, and organs, and tissues, which are the sources of 
all the forces which work the machinery, and without which we 
can have the manifestation of no vital phenomena. Brandy, Sul- 
phate of Quinia in large doses, and Carbonate of Ammonia, should 
have been promptly and freely administered, and sinapisms applied. 



MALAEIAL FEVER. 



187 



(b.) Active and excessive purgation should he avoided in malarial 
fever. 

AYe should avoid excessive purgation in malarial fever, for tbe 
same reasons that general and excessive bloodletting should be 
avoided. 

In malarial fever the blood-corpuscles are altered and destroyed 
to a great extent, and the fibrin and albumen are in a measure 
altered in quality and quantity. These alterations are attended by 
aberration and exhaustion of the forces, and although the alteration 
and destruction of the constituents of the blood may appear small, 
still they are sufficient to produce serious alterations in the secre- 
tions, and excretions, and serious disturbances in the forces. It is 
an established fact that excessive purgation exhausts the forces and 
diminishes the volume of blood. Excessive purgation, then, acts 
in concert with the malarial poison. 

Judiciously used, purgatives are of essential service in all those 
cases of malarial fever where there is a dry hot skin, dry red 
tongue, moderately accelerated full bounding pulse, and moderately 
accelerated respiration, and high temperature in the trunk and in 
the extremities. In such cases our plan has been to administer to 
an adult from eight to ten grains of calomel in combination with 
seven grains of sulphate of quinia, and follow with castor oil in four 
hours, and commence with five grains of sulphate of quinia as soon 
as the purgative has operated once or twice freely, and continue five 
grains every three hours up to twenty-five or forty grains, according 
to the symptoms of the case. I have in scores of cases seen the 
hot dry skin become relaxed and moist, and the dry harsh tongue 
become soft and moist, and the restlessness and pain in the head 
vanish, under the action of the calomel and sulphate of quinia. I 
have in scores of cases seen the most obstinate paroxysms yield 
without any return to the vigorous administration of the sulphate 
of quinia after the bowels have been opened, the skin relaxed, the 
secretions of the mouth and liver promoted, and the portal system 
unloaded. 

On the other hand, I have seen simple cases of remittent fever, 
converted into the congestive type, by the injudicious administra- 
tion of purgatives, and the neglect of sulphate of quinia, stimu- 
lants and sinapisms. The efficacy of this mode of treatment, as 
well as the true indications and methods for the employment of 
purgatives, will be fully discussed and illustrated by cases in a 
subsequent chapter. 



188 



OBSERVATIONS ON 



(c.) Support the strength^ during the severe attacks of malarial fever^ 
with nutritious diet and stimulants. 

If the action of the malarial poison be depressing and not in- 
flammatory; if the action of the malarial poison be destructive and 
not exciting, then nutritious diet and stimulants are indicated. 

I have administered milk punch, wine whey, beef soup, mutton 
soup, and soft-boiled eggs, with positive benefit in all the forms of 
malarial fever. The advantage of this mode of treatment is espe- 
cially evident in congestive fever, and in the severer forms of 
remittent fever, and in convalescence from all the various forms of 
malarial fever. 

The nutritious diet supplies the elements of the blood which 
have been destroyed, and the stimulants arouse the nervous sys- 
tems, and through them excite the action of the circulatory and 
respiratory systems, and promote the introduction and distribu- 
tion of the elements of nutrition and secretion, and of the chemical 
changes by which the forces are generated, and also preserve the 
elements of the blood and tissues from too rapid chemical change, 
by taking their places and themselves undergoing those chemical 
changes which are necessary for the development of the physical 
forces which works the machinery. 

We should never be deterred by the cerebral symptoms in ma- 
larial fever from the use of stimulants. They are due to the stag 
nation and congestion of the altered blood in the capillaries of the 
brain, as much, if not far more than to the direct action of the 
malarial poison. Hence, whatever will quicken the circulation and 
remove this, congestion and stagnation will promote the normal 
action of the brain and nervous system. Under the action of 
stimulants and sulphate of quinia, I have seen the delirious subject, 
with parched skin, tongue, and lips, become quiet and rational, 
with relaxed moist skin and mucous membrane. The efficacy of 
this mode of treatment will be illustrated more fully hereafter. 

(d.) Administer the salts which are deficient in the colored hhod-cor- 
puscleSj as soon as the destruction of the colored blood- corpuscles has been 
arrestedj and the malarial poison removed or diminished. 

I have derived great benefit from the administration of the Phos- 
phates of Iron, Lime, Soda, and Potassa, in the stage of convalescence 
from malarial fever. 



MALARIAL FEVER. 



189 



(e.) If after the active stages of malarial fever the digestive functions 
are enfeebled^ pepsin should he administered. 

Cases of neglected or badly treated malarial fever frequently 
run into what is commonly called the typhoid state, in which the 
digestion is enfeebled and perverted, the liver deranged, the spleen 
disorganized and in many cases degenerated, the blood-corpuscles 
diminished and altered, and the whole constitution of the blood 
profoundly altered. In these cases we have employed pepsin with 
benefit. If the gastric juice does not perform its of&ces, the active 
and essential principle of the gastric juice should be supplied. If 
pepsin and an acid be supplied, digestion will take place in a weak, 
diseased stomach as well as in the healthy stomach. The truth of 
this assertion has been established by the experiments of Dr. L. 
Corvisart,^ of Paris, to whom the profession is indebted for the in- 
troduction of pepsin into the practice of medicine. Andral, Longet,^ 
Eilliet, Barthez,^ Grisolle, Herard, Yogel, Schiflf, Josi, Lecointe,'' Bal- 
lard,^ Bertholet,^ Cahagnet,^ Parise,^ Huet,^ Chambers,^® Nelson," 
and others,'^ have testified to the efi&cacy and value of pepsin in 
various diseases. 

' "Dyspepsie et Consomption — Usage de la Pepsine." By Dr. L. Corvisart. Paris, 
1854. " Recherclies ayant pour but, d'administrer aux Malades que ne digerent 
point des Aliments tours digeres par le Sue Gastrique des Animaux;" Comptes 
Rendus, Aug. 16, 1852 — Sept. 6, 1852. "Etudes sur les Aliments et Nutriments — 
Nouvelle Methode pour le Traitement des Malades dont I'Estomac ne digere point;" 
L'Union Medicale, 1854, p. 17. 

2 In typhoid fever. Bulletin Gen. de Therap., torn, xlvii. p. 320. 

3 " Sur I'Apepsie (un absence de digestion) chez les Enfans, et sur le Traitement 
de cette Maladie par la Pepsine ;" L'Union Medicale, Jan. 12, 1856. 

* " Observation d'un Gas de Consomption ultime, traitee par la Poudre Nutri- 
mentive;" Bulletin Gen. de Tberap., tom. xlix. p. 268. 

^ Artificial Digestion as a Remedy in Dyspepsia, Apepsia, and their Results. By 
Edward Ballard, M. D. London, 1857. This valuable work contains the method 
of preparing pepsin, and also reports of numerous cases of disordered digestion 
successfully treated with pepsin by Dr. Ballard and other practitioners of medicine. 

^ In dyspepsia of a year's duration. 

' In dyspepsia and vomiting of several years' duration. 

^ In dyspepsia of early pregnancy. 

9 Gastralgia of several years' duration. 

'° "Practical Lectures on the Management of Digestion in Disease," by T. K. 
Chambers, M. D. ; London Lancet, Aug. 1857, p. 101, Sept. 1857, p. 180, Am. ed. 

" "On Mellitic Diabetes, in reference to its Treatment by Rennet or Liquor Pepti- 
cus Prsep.," by David Nelson, M. D. ; London Lancet, Aug. 1857, p. 118, Am. ed. 

>2 "Rennet in Diabetes Mellitus," by Dr. James Gray; Glasgow Medical Journal, 
Oct. 1856. See also American Journal of the Medical Sciences, Jan. 1857, p. 25. 
"Case of Diabetes Mellitus, treated by Joseph Jones, M. D. ;" Southern Medical 
and Surgical Journal, May, 1858. 



190 



OBSEEVATIONS ON 



When pepsin can be obtained pure from the apothecaries, or 
when the physician has time to prepare it himself, the poudres 
nutrimentives of Corvisart is by far the most elegant and portable 
preparation. Chambers^ and others^ have shown that much of the 
pepsin now sold possesses but feeble transforming powers, and it 
is important that the physician should be able to prepare it when 
needed. The following are the directions given by M. Boudalt^ 
for the preparation of the medicine: "Take a sufficient number of 
rennet bags (the fourth stomach of the ruminants), open and re- 
verse them, and wash them under a thin stream qf cold water; 
scrape off the mucous membrane, reduce it to a pulp, and macerate 
it in distilled water for twelve hours ; filter ; add to the liquor a 
sufficient quantity of acetate of lead, and, after separating the pre- 
cipitate, pass through it a current of sulphuretted hydrogen; filter 
again ; evaporate at a low temperature to the consistence of a 
syrup, which is mixed intimately with starch, pulverized, and dried 
at a temperature of 100° Cent. In this state the gentle application 
of heat will reduce it to a dry mass, readily reducible to a powder 
of uniform efficacy." 

The power of the pepsin thus obtained varies, and before the use 
of a specimen we should first test its transforming powder. The 
standard dose is that quantity of the powder which, when acidu- 
lated with three drops of lactic acid, and added to fifteen grammes 
(225 grains) of water, would transform (digest) six grammes (90 
grains) of fresh fibrin, finely cut up, and kept in a bottle, at a tem- 
perature of 40° Cent., for twelve hours, with occasional shaking. 
The average dose of the "poudre nutrimentive" is fifteen grains. 
It may be taken dry or in solution, in unfermented bread, or in 
a spoonful of soup, or in sweetened water. It should always be 
taken with, or at the commencement of, the meal on which it is 
to act. 

The following mode, adopted and recommended by Dr. James 
Gray,'' for the preparation of rennet, is far less complicated and 

' "Experiments upon Artificial Digestion," by T. K. Chambers, M. D. ; London 
Lancet, Aug. 1857, p. 133, Am. ed. 

2 "Experiments upon the Action of Pepsin," by Edward H. Sieveking ; Medical 
Times and Gazette, April 4, 1857. See also American Journal of the Medical Sci- 
ences, July, 1857, p. 212. 

3 Ballard on Artificial Digestion, p. 10. See also " Memoire sur le Principe Di- 
gestif, les Preparations Nutrimentives, et les Moyens propres a reconnaitre et a 
mesurer leur Action;" Acad. Imp. de Med., Seance du 14 Fevrier, 1854. 

^ Glasgow Medical Journal, Oct., 1856. See abstract of paper in American Jouru. 
of Med. Sciences, Jan., 1857, p. 215. 



MALAEIAL FEVEE. 



191 



tedious, and at the same time yields a valuable preparation of 
pepsin : — 

"The stomach of a calf (and the younger it is the better) is gently 
washed with water, taking care not to injure the mucous membrane; 
it is then salted, tied up, and allowed to dry. After this it is cut 
in small pieces, macerated in a pint and a half or two pints of 
water, according to the size of the stomach, for four days or longer 
in winter, shaking it at intervals ; the fluid is then poured off and 
bottled, and to test its power a spoonful may be added to a pint of 
warm milk, which, if it curdles, it is now fit for use. A little 
spirits, or decoction of sparrow-grass, may be added to make it 
keep. The dose of rennet thus prepared is a tablespoonful, three, 
four, or six times a day, about half an hour after each meal, and 
during the process of digestion, followed shortly after by an alkali, 
to neutralize the lactic acid formed. That which I recommend is 
the alkaline tribasic phosphate of soda; but the carbonate of potash 
will answer very well, either alone or combined with the tincture 
of nux vomica, in five or ten drop doses." 

The stomach of the pig may also be employed. It may be pre- 
pared in the way recommended by Dr. Gray in the preparation of 
rennet, or it may be cut in thin slices and treated with vinegar, and 
the digested mass added to mutton or beef soup. 

Pepsin is not the only substance concerned in the digestion of 
albumen and flesh. 

The connective tissues and muscular fibres are disintegrated and 
softened, but never completely dissolved by the gastric juice. The 
ultimate fibrillse of muscles, which have escaped the action of the 
gastric juice, pass into the small intestines, and are there digested 
by the pancreatic juice. 

Whenever, then, meat passes entirely through the alimentary 
canal without being dissolved, we conclude not only that the pepsin 
is deficient, but also that the pancreatic juice has lost its power of 
digesting the ultimate fibrillas of the muscles, which have escaped 
the action of the gastric juice. 

Whenever the ultimate fibrillae alone are discharged by the rec- 
tum, we must conclude that the pancreatic juice, and not the gastric 
juice, is at fault. In distinguishing derangements of the pancreatic 
from the gastric digestion, the microscope, applied to the matters 
thrown off from the rectum, is absolutely necessary. 

As far as my observations extend, the pancreas is less affected 



192 



OBSEKVATIONS ON 



during the process of malarial fever, than the liver, spleen, or sto- 
mach ancl intestinal canal. Notwithstanding these negative results, 
it is important that we should know the value of treatment in de- 
rangements of the pancreatic digestion. 

M. L. Corvisart^ communicated to the Imperial Academy of 
Sciences, April 6, 1857, a memoir "On the Power of the Pancreas 
to Digest Azotized Food," in which he not only confirmed the 
assertion of Purkinge and Pappenheim, that the secretion of the 
pancreas is endowed, like the gastric juice, with the property of 
dissolving azotized food ; and demonstrated that the pancreatic 
juice in disintegrating albuminoid elements effects in them a trans- 
formation identical or analogous to that which the stomach pro- 
duces ; but also showed that the pancreatic juice acts only on those 
portions of the food which have escaped the action of the gastric 
juice, and at the same time has no effect upon the digested products 
of the stomach. 

When separated, the pancreatic and gastric fluids exercise their 
functions in full, and, when mingled in their pure state, the two 
digestions are arrested. The two ferments, pepsin and pancreatin, 
destroy each other. 

In the alimentary canal, this is prevented, 1st. By the pylorus 
which separates the two ferments. 2d. By the gastric digestion 
during which the pepsin is destroyed. 8d. By the bile which 
destroys in its course the activity of the pancreatin. 

It is evident, therefore, that the pancreatin, or the pancreatic 
juice, so far from assisting digestion, would retard it. M. S. Cor- 
visart states that he had failed to receive any benefit from the 
administration of pancreatin for the relief of derangement of the 
digestion in the intestinal canal. 

My own limited experience with pancreatin sustains the state- 
naents of M. S. Corvisart. 

It is evident, therefore, that in the present state of science we 
are unable to reach, by medicines, the derangements of the pan- 
creatic digestion of flesh. Nevertheless, the determination of the 
relative frequency, extent, and effects of derangements of the pan- 
creatic digestion, is of great value. As far as my observations 
extend, these derangements are exceedingly rare in malarial fever. 

1 Moniteur des Hopitaux, April 21, 1857. See also American Journal of Medical 
Sciences, July, 1857, p. 206. 



MALARIAL FEVER. 



193 



(f.) The excretion of the products resulting from the dead disintegrated 
blood-corpuscles should be promoted by diuretics and depurants. 

The necessity for the removal of these products is indicated by 
the fact that the urine in congestive fever is deficient in the com- 
pounds resulting from the chemical changes of the blood and tissues; 
whilst in intermittent and remittent fevers, in which the elevation 
of temperature and the chemical changes correspond to the accele- 
ration of the respiration and circulation, the urine is loaded with 
the matters resulting from the chemical changes of the blood, and 
organs, and tissues, and apparatuses. 

The Sulphate of Quinia appears not only to exert a direct effect 
upon the actions of the sympathetic and cerebro-spinal systems, 
and upon the action of the heart and capillary circulation, but it 
also promotes the removal of the products of the metamorphoses 
of the tissues. 

The infusion of Yirginia Snakeroot is valuable as a stimulant 
and diuretic. 

The Bicarbonate, Citrate, and Acetate of Potassa, and the Carbo- 
nate and Acetate of Soda, are valuable depurants, both in the active 
stages and in convalescence. 

(g.) The liver and spleen should be roused to action if torpid^ and 
their perverted secretions thrown off^ and their normal relations to the 
blood re-established. 

In addition to the depurants just mentioned, we may employ 
the various preparations of iodine, especially the iodide of quinia ; 
and, in some cases, the preparations of mercury in small doses. 

I have witnessed the beneficial action of the iodide of quinia, 
both upon myself and upon others ; and, as far as my experience 
extends, it appears to act more powerfully upon the kidneys, and 
depurate the blood more thoroughly, and restore the stomach, 
liver, and spleen more rapidly to the exercise of the normal func- 
tions, than either of those substances uncombined. The iodide of 
quinia is worthy of the examination of the profession. 

The citrate of iron combined with the sulphate of quinia and the 
carbonate of soda, dissolved in the infusion of quassia, appear not 
only to assist in the restoration of the colored blood-corpuscles, and 
depuration of the blood, but they also appear to exert decided 
beneficial influences upon the liver and spleen. 



194: 



OBSERVATIOXS ON 



The next ]oomts of interest are the determination of the place of the de- 
struction of the color edhlood- corpuscles^ and the discussion of the question 
ichetlier their disappearance he entirely due to the cessation of their hirth. 

Do tliej diminish simply because new ones do not take their 
place ? 

With reference to the place of the destruction of the colored 
blood-corpuscles, it may be affirmed that they undergo important 
alterations in the spleen and liver, during the active stages of ma- 
larial fever. In examinations of the organs after death from all 
the forms of malarial fever, intermittent, remittent, and congestive, 
I have observed that the dark blood of the spleen and liver does not 
change to the arterial hue when exposed to the oxygen of the 
atmosphere. 

After death from phthisis, cirrhosis of the liver, organic disease 
of the circulatory apparatus, apoplexy, and mechanical injuries, so 
far as my observations extend, the blood of the spleen and liver 
always changes to the arterial hue upon exposure to the action of 
the oxygen of the atmosphere. Chemical examinations of the blood 
of the liver during health have shown that the blood-corpuscles 
are more numerous in the blood passing out of this organ than in 
the portal blood. 

The colored blood-corpuscles appear to originate to a certain 
extent in the liver, and undergo certain important chemical and 
physical changes in this organ. 

In malarial fever, important changes take place in the blood 
passing through the liver ; many of the colored blood-corpuscles 
are destroyed, and the coloring matters infiltrate the structures, 
and, together with the altered bile, impart the slate color to the 
exterior, and the bronze color to the interior, of the malarial fever 
liver. In some cases the colorinsr matter derived from the disin- 
tegrated blood-corpuscles, exists in the form of granules in the 
tissues of the liver. These granules, however, are by no means 
necessary to the slate and bronze color. 

I have discovered a similar change of color in the kidneys of 
several patients, which presented several spots upon their surface 
of a dark slate color without, and bronze color within. If the 
blood-corpuscles were destroyed in the capillaries of the kidney, 
then the destruction was circumscribed, and the peculiar coloring 
matter resulting from the changes of the coloring matters of the 
blood, infiltrated only those parts of the kidney adjoining the blood- 
vessels and capillaries in which they were destroyed. 



MALAKIAL FEVER. 



195 



This curious phenomenon has been also witnessed in the livers of 
patients who had died suddenl}?- in the earliest stages of malarial 
fever. In these cases the greater portion of the livers have pre- 
sented a color but a few shades deeper than the Spanish brown ; 
whilst one or more spots were found presenting the true malarial 
slate and bronze color. These facts illustrate two points. First, 
they show that the destruction of the colored blood- corpuscles in 
the liver commences at an early day in the liver ; and second, that 
this destruction in some cases, at least, is confined at first to circum- 
scribed portions of the liver. 

Whilst the facts as yet accumulated are too few to warrant any 
very general or dogmatic assertions, they certainly incline our 
minds to the belief that the destruction of the colored blood-cor- 
puscles in the liver are dependent upon the disturbance of the 
relations of the liver to the blood, rather than to the destruction of 
the colored blood-corpuscles in the capillaries and bloodvessels, 
independent of the action of the liver, simply by the direct action 
of the malarial poison. The changes of the blood in the liver are 
not confined to the destruction of the colored blood-corpuscles. 

Animal starch accumulates in the malarial fever liver; whilst grape 
sugar ^ as far as my observations extend^ is absent. 

I have made numerous ^os^wor^e??^ examinations in all the forms 
of malarial fever, and tested the livers carefully for animal starch 
and grape sugar. The result was the same in every instance ; an 
abundance of animal starch without a trace of grape sugar. When 
the malarial fever livers were washed, and small particles spread 
upon a glass-slide, and treated with tincture of iodine, and viewed 
under the microscope, numerous beautiful blue and purple masses 
of this animal starch, colored by the iodine, could be seen. When 
the fibrous capsules of the livers were torn off from the surface of 
the liver, and spread upon a glass-slide, and treated with tincture 
of iodine, these blue masses were seen scattered amongst the meshes 
of the fibrous tissue. The livers were set aside and examined after 
intervals of twelve hours. The last examination was made thirty- 
six hours after the first. At every examination the result was the 
same ; an abundance of animal starch, and no grape sugar. 

These facts are important, not only in their bearing upon mala- 
rial fever, but also in their bearing upon other diseases. M. CI. 
Bernard has demonstrated that the transformation of glycogenic 
hepatic matter (animal starch), formed by the liver, into glucose, is 



196 



OBSERVATIONS ON 



the result of the action of a special ferment, which is formed and 
exists in the blood, independent of the liver. From these facts it 
is probable that in malarial fever this ferment is destroyed ; whilst 
the liver still possesses the power of transforming the nitrogenized 
and non-nitrogenized elements into animal starch. 

The blood and blood-corpuscles undergo remarkable alterations in the 
spleen during malarial fever. 

Upon the exterior the malarial spleen presents a dark slate color, 
resembling the color of the malarial liver. When held in the hand 
the malarial spleen feels like a bag of soft mud. The capsule and 
trabecule break upon the slightest pressure, and the fingers will 
often plunge into the organ, even during the most careful hand- 
ling. 

The reddish-brown mud (pulp) of the malarial spleen consists 
almost entirely of colored corpuscles in various stages of alteration 
and disintegration. 

With the microscope I have found that in many cases, especially 
those of long-standing, the mud of the spleen contained numerous 
granules of a reddish-black color. These black granules were fre- 
quently conglomerated together, forming dark flakes, like the coffee- 
ground sediment of the black vomit of yellow fever, and were 
without doubt altered colored blood-corpuscles. In many spleens 
the colored blood-corpuscles have presented swollen, and distorted, 
and irregular forms. I have found this alteration of the spleen in 
all cases and in all periods of malarial fever. In one case, in which 
the patient died in thirty hours after the commencement of the 
attack, the spleen presented the same enlarged and softened condi- 
tion ; whilst the liver presented only spots of the slate and bronze 
color. 

When we reflect that the malarial fever spleens often weigh one, 
and two, and three or more pounds, and that their principal weight 
is due to the presence of colored blood-corpuscles ; when we further 
reflect that the whole amount of blood existing in the body of a 
grown man is about twenty pounds, and that not more than nine 
pounds of this exist in the form of moist colored blood-corpuscles, it 
is evident that the spleen in malarial fever forms a grand sepulchre 
for the colored blood-corpuscles. We will show in the chapter 
upon the changes of the organs and apparatus in malarial fever, 
where these subjects will be more fully discussed, that the mud of 
the spleen is not reabsorbed to any great extent. 



MALARIAL FEYER. 



197 



"We have before discussed the alterations of the fibrin, and the 
changes of the color of the serum ; it remaias now to state that the 
albumen is diminished in malarial fever ; whilst the extractive 
matters of the serum are increased. 

Professor Cozzi has also shown that the cholesterin was increased 
in the blood; whilst the phosphates, and fat, and albumen were 
diminished. Whether the cholesterin was derived from the bile or 
from the brain, or from both, has not been determined. 

We will now compare the changes of the blood in malarial fever 
with those of other diseases. 

The following table, constructed from a minute and laborious 
examination, and calculation, and classification of the most im- 
portant researches upon the changes of the blood in disease, will 
give a condensed resume of this department of pathological che- 
mistry: — 



198 



OBSERVATIONS ON 





1 


2.3 
1.3 
2.3 
2.1 
1.6 
1.3 
1.0 
2.0 
3.7 
3.6 
5.0 
5.7 
5.0 
4.0 
3.6 
2.9 

2 3 
1.9 
3.7 
3.4 

3 5 
2.3 
1.7 
2.1 
0.9 
2.4 
4.2 
0.0 
2.6 

2.01 

5.00 

1.71 

3.26 

2.3 

1.2 




nil 


||:::::::::::::::::::::::::::::::::: 




"■I i 






< a 


64.4 
62.0 

80.33 


i 1 


li 


iiiiiisiiiiiiiiiisiiSssKlSiiiiiii 


i 1 
1 1 

< s 


1 


0«05T)<»i»r-ICOC0005r^eOCOCOC5r^OOO(>501>050r50COr--IOO-t'-HC;0'~0 

mmtmmmimMmmmmmmimm 


§ 1 




iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii 




il 

a 


mMmmmmmmmMBm 




1 


iiiiiiiiiiiiiiiiiiiiiiiiiiiiiii 








: :'^-'^=^SS^^^=°SS;2;*S?^S?3*SS^;^'"'= :::::::::: 




:::::::::::::::::::::: : ig:^^?^^^^^ : : 




REMARKS. j 


Moan 
Meau 

Case 1 . . \' 
Ca.so 2 . . 

- 

Ca.so 3 . . ' 
Cawo 4 . . - 

Case 5 . . - i 

Case 6 . 
Ca.so 7 . 
Maxima . 
Minima . 
Mean . . ; 

Maxima . 
Minima . 

Malo, Case 1 . 
Malo, Case 2 . ; 



MALARIAL FEVER. 



199 



I 



1000 PARTS OF BLOOD CONTAINED— 




1 


cqcdciuq d T)H (^i M CO CO CO CO *4 M -i^ (^^ (N 00 rH 10 CO ' • c^i ^ S <?4 s4 co' S o? cq' ^' m' 


t 


i 






m 




ii 


:::: 5:::::::::::::::::::::::;:::::: 


i 


if 


i-H r— ( I— li— <i— ) r— ( I— IrHrHi— 1 I— IrHi—lrHr— irHrHrHi— IrHr— IpH r-lrHrHr-lrH 


1 


iiii iiiiiiiiiiiiiiiiiiiiliiiiiiiiii 


i 


iiii iliiiiiiiliiiililiiiiiiiiiiiiii 


Ii 


(MrHi— ii—i c^(^^(^^MC<^Ml-HrHC^(^^^^^clT-^c<^(^^^^^(;^c<^!N<Nc^c<^c<l^^^(^^r-l (Noioq 




OO^.t^CO CDOC0^1C00=CCC0-t;OOt-O«.OC00,O^.0^0.C0^ COt^O 

iiii gSiigiS^sSisigFgi^gligiipS ' -lis 

t>i c/j c/j !>• l>* CO 1^- 'Vj (/J cyj r— i>- r-- t-- co i^- !>• l>- 


•sSntp89iq JO -0^ 


• • • • 'MC^COrHC^^CO-^^rHC^rHC^i-HrHCNrHrH • .rHr— lrHr-(C^rHC^r-(C^ • • • 






:::: ::::::::::::::::::::::::::: :,g| 


•snot:) 
-■BAaasqo jo "o^ 




REMARKS. 


Male, Case 3 , 
Male, Case -1 . 
Female, Case 5 
Female, Case 6 

Casel . . ! 

Case 2 . 

Case 3 . 

Ca.se 4 . 
Case 5 

Casel . . j 

Case 2 . 
Case 3 . 

Case'l . "*. 

Case 2 . 
Case 3 . 

Case 4 . 
Case 5 . 

Man, Case 1 , 

Man aged 48 . 
]\Iau aged 21 . 
Man aged 32 . 


DISEASES. 


■ -1 




Typhus Fever 

Ephemeral F: 
Continued I 
Small-Pox 

Scarlatina 
Measles 

Acute Scurvy 
Chronic Scura 


OBSERVERS. 


M. H. Guenaud de 
Mussy & M. Rodier 

Becquerel & Rodier 
Andral & Gavarret 

Lecanu . 

Andral & Gavarret 

Becquerel & Rodier 



200 



OBSERVATIONS OK 



mi 



: :S2§ :5S§22SS2 :3S3 



IN 



III : 



iiiiiiiiiiiiiiiiiiiiiiSiiiiiiiiiiii 



i 



iiiiiiiiiiiiiiiiiiiiiiiiiiiiaiiiiii 



ii 



i-HOrHrH00MTj<OC0C0C0C0rH'#>0OTHO^OC0OrHQ0»r50lOO<N<N(NOO(NC<JO 



mmmmmmmMmMimii 



li 



• CO <M CO CO lO c 



•snop 
-■BAjasqo JO "0^ 



r-l fO Ti< 



.1 

I iMIIIIII 

1 alllllii 



III 



I ^ ••• -g. ..... . 1^ 1^ = |. . • 

^ J ■=« o 



MALAEIAL FEVER. 201 





Fibrin. 








5.7 

6.6 

5.0 

6.0 

6.3 

6.8 

6.2 

7.27 

6.5 

6.4 

6.6 


1 








is 




1 
s 




BLOOD 


i il 

i "a 


mmMimmmmmMmmi 


1000 PARTS OF 


I 1 

§ ^ 


i^rnmmmmmmmmm 


i ill 


iiiiiiiiiiiiiiiiiiiiiiiiiiiliiiiiiiii 




ii 


S 55 ffl S <N Cq rH (N N rH r-l rH r-l rH M rH r-l r-l rH rH r-l r-l (N Cq S 




1 


-*OOi-l0001-H(Ml^r-('^0<r>.0 001t^03l^~-HCO ^ <X>MOM CO -H 

mmimmmMimm ■■ -4 ■■ mi ■■ ■■ 






•8S^8STP JO £^a 






..................... :0|0««COCO . . 










i 






i 


. Male . 
. Male . 
. Male . 
. Male . 
. Male . 
. Male . 

Mean 
, Female . 
. Female 

Female 
. Mean 

• Case 1 

Case 2 

Maxima , 
Minima , 
Mean 
. Maxima 
Minima 
Mean 

. Maxima . 

Minima 
. Mean 
. Maxima , 
. Minima , 
. Mean 






1 i. 












Scrofula 

Carcinoma 

Brioht's Dise. 

Bright's Dise. 
Chlorosis 

Anemia , 





















14 



202 



OBSERYATIOXS OX 



I 













iii 


8 




1 








iji 


rHCO>c-#i:^c;ocOr-ic-. t^c-.t-ccc:cc:r-i?i?i-t't^~5';;-+OCii>-:ocq-oorit-o 

„• r/, ro c^' 1-.' -Ni — ■ 1-^ h~' — ■ — ■ -si j-" i-,: — ' -r-' -X -u' -c' '-' -X -X -J ,-. — ' _; • • 


BLOOD CONTAII 


li 








ii 




ARTS OF 








fin 

1 


i 


i 






il 






1 


^ -f. ^. «. ^. * ^. ^. -1 =>. =. ^. R ^. R ^. - "--^ =>. 

EiiisiiiiiiiiiRiigsiiSiiaggiiHiiiSlii 


JO Ava 




-^A.T8sqo JO -ox 


:::::::::::: i^^^SSS^ :::::::::::::: i'^'^ 



• • • § § • s 

iiiif ifiiirir' 
lull liiiiiiill 



I I I 



Jim 



Li.... 



22 «2 33232322 



it 



|3 2 §2 2 |3 1= - ^ - — — = — — 



::;:::::::::i,.,Jl.„.,„„,J: 

P< ^22322 ---3222233232222 =:-2 

. = = = = = = . = : = ! 5 



MALAEIAL FEYEE. 



203 



•i 

1 



nil 



ii 



ii 



OOClGO-fOqC20r-!0-f<CC--DCCt~^.-^(M-H-+<-tHCOOCCCO . . . .C0-l'-«fC^0^3 



:|::::::::::::iiiS::::|| 



iiiiiiiiiiiiiiiiiiiiiiliiiiiiiiiiii 



iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii 



iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii 



iiiiiiiiiiiiiiiiiiiiiliiiiiiiiiiiiii 



•sSmpeaiq jo -oij 




•snoi; 






J 1 1 'T J J IJJiil i J ■ 


1 

ft 




::::;::::::;::r:: 




Tleuiutis 

rKRITONITIS , 

Aniiina. Tons 11 

Acute Bkonch 

CAitniTis 

Pericarditis , 
Inflammation 
Glanders 
Lead Poisonin 


OBSERVERS. 


Andral & Gavarret 

Becquerel & Rodier 
Andral & Gavarrot 

Becquerel & Rodier 
Andral & Gavarrot 
Lecanu . 

Becquerel & Rodier 
Popp 



204 



OBSEEVATIONS ON 



The comparison of the character, progress, and duration of the 
diseases in those cases from which these observations were derived 
(so far as the records extended), with the character, progress^ and 
duration of the cases of malarial fever observed and recorded by 
ourselves, and the comparison of the results of the chemical ex- 
amination of the blood in various diseases (allowing due weight to 
the different methods employed by different observers) with the 
results of our chemical examination of the blood in malarial fever, 
have forced upon my mind the conclusion tJiat^ so far as these ohser- 
vations extend^ the colored hlood- corpuscles are more uniformly and 
rapidly destroyed in severe cases of malarial fever than in any other 
acute disease. 

We would state, distinctly and unequivocally, that this statement 
applies only to those results of investigation which are now before 
the profession. 

This department of pathological chemistry may, with truth, be 
said to be in the imperfect and undeveloped state of the embryo. 
We know little or nothing definitely concerning the changes of the 
blood in yellow fever, and in the states induced by numerous poi- 
sons; and our knowledge, in almost every instance, extends no 
further than the destruction, or undefined alteration, of one or the 
other constituent, and does not penetrate beyond the exterior ^hj- 
sical and chemical changes, and reveal the relations of the sub- 
stances destroyed or altered to the poisons, or substances resulting 
from the action of the poisons. 

When not merely the facts of the destruction or alteration of the 
constituents of the blood in all diseases have been determined, but 
also the causes of their destruction and alterations, and the methods 
and results, chemical, physical, physiological, and pathological, have 
been definitely determined ; then, and not till then, will it be pos- 
sible to draw broad lines of distinction between diseases, based 
upon the chemical, and physical, and physiological, and pathological 
alterations of the blood. Nevertheless, the first step in the right 
direction is to perceive and appreciate the extent and bearing of 
the established facts, even though they be imperfect, and superfi- 
cial, and meagre. 

In comparing these results, it should be remembered that the 
individuals whose blood I examined were, as a general rule, stout, 
athletic seamen and laborers, who had never before been attacked 
by the malarial fever, and who had been exposed but a short time 
to the malarial poison. 



MALARIAL FEVER. 



205 



This table further shows that in certain states of the system — as 
the cancerous and cachectic, and in such as are induced by long 
starvation, and exposure, and improper habits, and by hemorrhages, 
scurvy, and Bright's disease — the blood-corpuscles are greatly dimi- 
nished. These results do not invalidate the conclusion that blood- 
corpuscles are most rapidly destroyed in severe attacks of malarial 
fever, because the destruction accomplished by the slow action of 
the causes inducing these states of the system required months or 
even years, whilst an equal or even greater destruction may take 
place in a few days or weeks in malarial fever. 

We affirm, and our affirmation is borne out by the results here 
recorded, that the colored blood-corpuscles are diminished during 
the progress of all acute diseases. Andral & Gavarret have shown 
that the idea which they promulgated in their earliest researches, 
that the blood-corpuscles are increased in the earlier stages of 
typhoid fever, was erroneous, and arose from the fact that this 
disease most frequently attacks those whose blood is rich in colored 
blood-corpuscles. The suspension of the process of digestion, and 
the perversion and partial suspension of secretion and nutrition, 
and the rapid chemical changes and corresponding rapid metamor- 
phosis of matter — the universal attendants, or rather phenomena, 
of acute diseases, must necessarily be attended by a destruction, to 
a greater or less extent, according to the severity of the disease, 
of one or all the constituents of the fluid which supplies the ele- 
ments for secretion, nutrition, and chemical change. 

These can ses produce destruction of the colored hlood- corpuscles in all 
acute diseases; hut in malarial fever we have an increased destruction 
which cannot he referred to these causes. 

We have before shown that the blood-corpuscles suffer profound 
alterations in the liver and spleen during the active stages of mala- 
rial fever ; and, in attempting to account for the different degrees 
of destruction of the colored blood-corpuscles in different diseases, 
this fact leads us to institute an examination and comparison of the 
lesions of these organs in different diseases. 

In typhoid fever, the spleen is almost always more or less altered 
in appearance. Its volume is augmented, in many cases, to three 
or four times the natural size, and the parenchyma reduced to a 
soft pulpy mass. The cases of typhoid fever in which the size of 
the spleen is most augmented, and the tissues most softened and 
broken down, are those which terminate most rapidly. In forty- 
six examinations of the bodies of those who had died with typhoid 



206 



OBSERVATIONS ON 



fever, Louis found this organ in its natural condition only four 
times. This enlargement and softening of the spleen appear to be 
in typhoid, as well as in malarial fever, the result, not of inflamma- 
tion, but of congestion. Whether this congestion be the result of 
disturbances in the circulatory apparatus and nervous system and 
contiguous organs, or of the direct action of the malarial or typhoid 
poisons upon the spleen, will be more fully discussed hereafter, and 
do not bear directly upon the question now under consideration. 

This source of the destruction of the colored hlood- corpuscles exists^ 
theUj m both typhoid and malarial fevers. The enlargement of the 
spleen, however, is greater in malarial fever. Whilst, therefore^ 
there should be a destruction of colored blood-corpuscles in the 
spleen in both typhoid and malarial fevers, this destruction should 
be somewhat greater in the malarial spleen. 

We will next compare the lesions of the liver in these diseases. 
So far as pathological investigations (which, it must be confessed, 
have been confined almost exclusively to the mere physical altera- 
tions of this organ, the color and consistence) extend, nothing has 
been discovered in the condition or secretion of the liver peculiar 
to typhoid fever. 

According to Andral, the liver almost constantly presents a 
healthy appearance. 

Louis^ found slight softening in about one-half of the cases of 
typhoid fever examined by him. It is probable that the softening 
of the liver in these cases resulted from commencing decomposition. 

Pathological investigations, then, indicate that the blood-cor- 
puscles are not destroyed in the liver of typhoid fever, as they are 
in this organ during malarial fever. 

ZTere, then^ is a marked difference between typhoid and malarial fever, 
and the cause why the destruction of the colored blood- corpuscles is more 
rapid in the latter than in the former. 

Dr. Gerhard,^ in his observations upon typhus fever, states that 
the spleen was of the normal aspect in one-half the cases; in the 
other half it was softened, but not enlarged ; and in one case out 
of five or six, enlarged and softened. 

Dr. Jenner examined the spleen in thirty-four subjects above the 

1 Anatomical, Pathological, and Therapeutical Researches upon the Disease 
known under the names of Gastro-Enteritis, Putrid Adynamic, Ataxic and Typhoid 
Fever, by P. Ch. A. Louis, 2 vols. Paris, 1829. 

2 Am. Journ. of Med. Sci., Feb. 1837 



MALAEIAL FEYEE. 



207 



age of fifteen, who died before the terminatioD of the fourth week 
of the disease, and found the average weight to be seven ounces and 
five drachms. 

According to the observations of Dr. John Eeid, the weight of 
normal spleens ranges from 2187 to 3062 grains. It is evident that 
in these cases, reported by Dr. Jenner, the spleen was but slightly, 
if at all, enlarged. 

Dr. John Home examined after death one hundred and one cases 
of typhus fever, and found that the spleen was generally larger than 
usual, soft, and in some cases almost diffluent. In one instance this 
organ weighed eleven, and in another fourteen, ounces. 

These observations, together with those of many other investi- 
gators, demonstrate that the lesions of the spleen are neither con- 
stant nor of any great extent. In some cases of typhus fever the 
liver has been found engorged with dark fluid blood, in others 
spotted with ecchymosis, and in many cases it was the seat of no 
appreciable lesion. i. 

All observers agree that one of the most striking facts in the 
pathological anatomy of typhus fever, is the absence of any con- 
stant and characteristic lesions. The most uniform and important 
alteration appears to be that of the blood, which is manifested not 
only in its appearance, physical properties, and chemical constitu- 
tion, but also in the rapidity with which the color of the skin 
changes after death, and the body undergoes decomposition, and 
the frequent occurrence of cold abscesses in various parts of the 
body after an attack of typhus fever. 

If there he no destruction of the hlood-corpuscles^ independent of the 
liver and spleen in typhus fever^ or if the destruction of the hlood- 
corpuscles in the bloodvessels and capillaries, independent of the spleen 
and liver, he not more rapid in typhus than in typhoid and malarial 
fever, then the destruction of the colored hlood-corpuscles should he less 
rapid in typhus fever than in typhoid and malarial fever. The obser- 
vations thus far recorded do not enable us to settle this question 
definitely, for the patients from whom the blood was abstracted (the 
analyses of which are recorded in the table) were hospital patients, 
natives of Ireland, whose disease appeared (from the accounts of the 
authors) to have been aggravated by previous want. "We know 
that this fever most frequently attacks those whose constitutions 
have been worn down, and their solids and fluids, especially the 
blood deranged by foul air and poor diet. 



203 



OBSERVATIONS ON 



In malarial fever, and in fevers generally^ the fibrin is rarely increased, 
and either remains within the limits of health, or is diminished, and, as 
far as my observations extend, the diminution of fibrin corresponds icith 
the severity of the disease. 

This fact corresponds with the results established by Andral in 
his splendid researches upon the blood. 

The distinction between the alterations of the blood in the py- 
rexias and phlegmasiae is thus pointed out by Andral : — 

"In my first memoir upon the alterations of the blood I have 
proved that the fibrin never augments in the pyrexiae, supposing 
them divested of all phlegmasial complication ; that it often remains 
in normal quantity, and that sometimes it diminishes to a point at 
which we do not find it in any other acute disease. 1 have shown 
that the pustules of variola, and the dothinenteric plaques of typhoid 
fever do not have the power of increasing the cipher of fibrin; and 
finally I have shown that with all the possible proportions of the 
globules, whether they were very abundant, or whether they have 
become very rare, a pyrexia could equally arise with all its varie- 
ties of form and gravity. But is it indifferently, and as it were by 
chance, that the fibrin shows itself in the pyrexiae, either in normal 
quantity, or in a proportion infinitely more feeble than in the phy- 
siological condition ? No, without doubt, and with regard to this, 
very clear general principles may be laid down. 

"At every period of clinical observation, and upon whatever point 
of view the observer was placed, it has been recognized that amongst 
the pyrexia there were some unattended by any grave symptoms, 
which marched naturally towards a favorable termination ; while 
there were others which, either at their commencement, or during 
their course, were accompanied by accidents of such a nature, that 
it seemed as though the forces which rule the organism were either 
vanquis,hed, or profoundly disordered to such an extent that the 
extinction of life must be the consequence ; and at the same time 
it was found that in such cases the blood presented an altogether 
peculiar appearance ; it was observed that as it became less con- 
sistent, it seemed to tend towards a sort of dissolution. 

"Admitted at all periods, but differently explained according to 
the prevailing theories, this condition, which may develop itself in 
any pyrexia, and towards which several seem to tend naturally, 
has been called, turn by turn, putrid, adynamic, and typhoid state ; 
it has its greatest development in the typhus fevers, properly so 
called ; it is in some sort inherent in them ; it is, as it were, their 



MALAEIAL FEVER. 



209 



essence. The pyrexia, now called typlioid fever, presents it in a 
slight degree from the invasion, and the grave cases of this disease 
are its marked representation. It does not ordinarily exist in the 
eruptive fevers, but it often complicates them, and constitutes one 
of their dangers. Finally, in addition to the pyrexiae, with well- 
marked characters, and which have a fully developed place in 
nosological systems, there are others to which no name has been 
given, which may yet present in a high degree the different symp- 
toms to which the ancients attached the idea of the putrid state. 
This is because there may exist in effect, in all the pyrexias, a com- 
mon alteration of which the blood is the seat, and whose existence 
constantly coincides with the appearance of those phenomena always 
the same, attributed by vitalism to adynamia, by solidism to relax- 
ation of the fibre, and by humorism to putridity of the humors. 

"This alteration of the blood consists of a diminution of its fibrin. 
It is consequently an alteration the inverse of that which betrays 
in the blood the phlegmasial condition." * * * 

" Since the diminution of the fibrin does not exist necessarily in 
any pyrexia, it is perfectly clear that it is not in this alteration of 
the blood that we should place the point of departure of this class 
of diseases. But what seems to me incontestable is, that the specific 
cause which gives them birth acts upon the blood in such a way 
that it tends to destroy its spontaneously coagulable matter, while 
the cause which produces the phlegmasise tends, on the contrary, 
to create in that fluid a fresh proportion of that matter. If this 
cause act with slight energy, or if the economy resist it, the destruc- 
tion of the fibrin is not accomplished. If, on the contrary, the 
cause continue to act with all its intensity, and the forces of the 
organism be in fault, the destruction of the fibrin will commence 
either at the very beginning of the disease— which is ver}^ rare — 
or at a certain period after its commencement. All this applies 
itself equally well both to typhoid fever, and to the eruptive fevers. 

"For me, there is in all these cases a true intoxication; if it be 
slight, its effect must, to be sure, always exist, but it is not appre- 
ciable; if the intoxication be stronger, the effect which it has pro- 
duced upon the blood becomes visible, and is marked, in that fluid, 
by a diminution of the fibrin. 

"Whilst, then, we establish, in certain forms of typhoid fever or 
scarlatina, that alteration of the blood which consists in a tendency 
to the destruction of its spontaneously coagulable matter, we no 
more attain by this means the true cause of the disease, than we do 



210 



OBSERVATIONS ON 



by studyiDg the alterations of which the tegumentarj membranes 
are the seat. But, as these alterations of the mucous membrane 
or of the skin, once produced, bear their part in the production of 
symptoms, just so does the peculiar alteration of the blood which 
may then arise bear its part."^ 

With this quotation, confirmatory in a great measure of our own 
views, we close the examination of the nature and extent of the 
changes of the blood in malarial fever ; not because we have by 
any means exhausted the subject, or even pointed out the full bear- 
ing of all the facts established by our own investigations, but 
because we are disinclined, to pursue a subject so imperfectly inves- 
tigated and developed ; because we wish to avoid unprofitable dis- 
cussions, which may be overturned by the first investigator who 
shall penetrate beneath the surface, or may lead to the adoption of 
erroneous principles of practice. We candidly confess that the un- 
known vastly exceeds the known, and that the great body of facts 
in this branch of pathological chemistry, are only surface facts, re- 
lating to the most superficial, exterior phenomena, and not to the 
relations and causes of phenomena. 

After we have established that the blood-corpuscles, and the 
fibrin, and the saline matters of the blood in malarial fever, or in 
any other fever, have been destroyed or altered, questions of great 
importance immediately arise. How are they destroyed? Are 
they destroyed by an actual, direct physical and chemical action of 
a special poison, or by the suspension of the functions of the organ 
or organs in which they are born, or by the chemical and physical 
changes of the liquor sanguinis in which they float? What are 
the physical and chemical changes which the elements of the blood 
and organs and apparatuses undergo, under the action of morbific 
agents ? 

The imperfection of pathological chemistry is strikingly shown 
in the state of our knowledge with reference to the fixed saline 
constituents of the blood-corpuscles and liquor sanguinis. Not- 
withstanding the brilliant researches of Becquerel, Eodier, and 
others, we still need, amongst many other things, a comprehensive 
and laborious investigation of the changes of the saline constituents 
of the blood-corpuscles and liquor sanguinis. It is not sufficient 
that the saline constituents of the entire blood, or of the liquor san- 

' An Essay on the Blood in Diseases, by Gr. Andral. Translated by J. F. Meigs, 
M. D., and Alfred Stille, M. D. PMladelphia, 1844. 



MALAEIAL FEVEE. 



211 



guinis, should be examined. The advancement of medical science 
demands that the relations between the fixed saline constituents of 
the blood-corpuscles and liquor sanguinis should be determined; 
demands that the variations and relations of the fixed saline con- 
stituents of every element of the blood should be determined in 
health and in disease. 

An important question now presents itself. 

Do these changes of the hlood precede^ or succeed^ or are they simul- 
taneous with^ the aberration of the 'physical^ chemical^ vital^ and nervous 
phenomena denominated fever f 

This question can be settled only by an appeal to nature. I have 
resided almost all my life in a malarious district, in the southern part 
of Georgia, and speak from observation. 

It is known to practitioners in malarious districts, that the con- 
stitution is sometimes undermined silently by the malarial poison, 
without the manifestation of febrile phenomena sufficiently marked 
to attract the attention of the patient or his friends. It is further 
known to the practitioners in our southern States, that the phleg- 
masise, especially pneumonia and pleurisy, and even the irritative 
fever succeeding amputations and severe wounds, will assume the 
intermittent, remittent, and even congestive types of malarial fever. 
That these types of inflammatory fevers are due to a state of the 
system permanently induced by the malarial poison, and also to 
the direct action of the poison during the inflammatory disease, is 
conclusively demonstrated by the mode of treatment most suc- 
cessful in these districts, and by the comparison of the results of 
this practice wdth that of healthy, non-malarious districts. 

It is an established fact, that bleeding and active purgation will 
not be borne in the pneumonia and pleurisy of malarious districts 
as well as in these diseases occurring in the primitive, non-malarious, 
middle regions of Georgia and other States. It is an established 
rule with many practitioners in the malarious districts of our 
southern States, to avoid large bleedings and active purgation in 
pneumonia and pleurisy, whilst the reverse rule has prevailed in 
non-malarious districts, having the same climate and relations to 
heat and moisture. 

It is known that the sulphate of quinia may be used with the 
greatest benefit and success in the treatment of pneumonia and 
pleurisy, and of the phlegmasise generally, and even of the irritative 
fever following amputations and severe wounds, in malarious dis- 



212 



OBSERYATIOXS ON" 



tricts; whilst no sucli beneficial effects attend the use of this remedy 
in these diseases occurring in non-malarious districts. 

These facts demonstrate that the malarial 'poison is capable of altering 
the constitution of the solids and flv.ids^ and modifying and altering the 
type and progress^ phenomena and effects^ of diseases^ even ivhen no 
symptoms of aberrated physical^ chemical^ vital^ and nervous actions 
vjere ma.nifested^ suffcient to attract the attention. 

The author has carefully noted the antecedents of three attacks 
of malarial fever in his own person, occurring within eighteen 
months, and separated from each other by intervals of perfect 
health. The first was an attack of bilious remittent fever, con- 
tracted in a malarious district, during repeated exposure to the 
night air at late hours of the night, and aggravated by exposure to 
the hot sun in the early part of August. 

For two weeks before the supervention of fever, the complexion 
assumed a sallow appearance evident to observers. The only un- 
usual sensations at this time were those of irritability and excite- 
ment of the nervous system. In this state, there appeared to be 
an increase rather than a diminution of mental and physical force, 
and I Avas surprised to find the strength sufficient for twelve hours 
of hard labor in the conduction of pathological, physiological, and 
chemical investigations, and hospital practice, notwithstanding that 
the rest at night was exceedingly imperfect. Several days before 
the commjencement of the fever, the bow^els were deranged; the 
discharges were copious and frequent, and appeared to contain 
much altered bile, resembling that so often found in the gall-bladder 
of the malarial liver after death. Isotwithstanding the superven- 
tion of this affection of the bowels, I was able to continue for three 
days, during the usual time (twelve hours daily), pathological in- 
vestigations and hospital practice. The fever which followed was 
high ; full rapid pulse, full moderately-accelerated respiration, high 
temperature, dry skin, dry tongue, high-colored urine, and, at one 
time, aberration of the intellect, preceded by intense pain in the 
head, and cold extremities. 

The fever yielded readily to the action of the sulphate of quinia, 
and, shortly after its removal, I recommenced my labors; and, not- 
withstanding frequent exposure to the night air at all hours, per- 
fect health was enjoyed for two months, at the end of which time 
I was troubled by periodical headaches, attended with derangement 
of digestion, the generation of much acid in the stomach, and high- 
colored urine, and, at times, with slight exacerbation of the pulse. 



MALARIAL FEVER. 



213 



and slight increase of temperature. There was never any chill, nor 
anything approaching to a chill, either at the commencement or 
during the continuance of these periodical disturbances of the sys- 
tem, which returned every seven, nine, eleven, or fifteen days, and 
lasted from twelve to forty hours. The headaches appeared to be 
often relieved, and always benefited, by the free administration of 
the bicarbonate of potassa. It was frequently noticed that uric 
acid and urate of soda were deposited in the urine excreted just 
after the disappearance of the headache. 

During the winter, I took up my residence in the town of Athens, 
situated upon the granite and gneiss hills of middle Gleorgia. The 
town and environs of Athens are without a single source of malaria, 
and its bills of mortality, and the appearance of its inhabitants, 
and the exemption of the students attending the University of 
Georgia from disease, show that it is one of the healthiest localities 
in the world. 

In this healthy locality, contrary to expectation, the headache 
increased in severity, and the strength of the muscular system 
diminished, and the nervous system became more excitable, and 
the person lost flesh. 

Up to the first of March, six months from the commencement of 
the periodical disturbances of the system, I had never been inca- 
pacitated a single day for the regular discharge of my professorial 
duties and investigations. At this time, after unusual anxiety and 
fatigue, a chill came on, in the evening of the day previous to the 
anticipated headache. During this chill the pulse was rapid, but 
feeble, the respiration was accelerated, full, and labored, the mus- 
cles trembled and shook, and the temperature of the extremities 
was many degrees below the normal standard, whilst the tempera- 
ture of the trunk was elevated several degrees above the "usual 
point of health. As we shall hereafter show, these were the phe- 
nomena of a true malarial chill. 

The succeeding hot stage was well marked by a full, rapid pulse, 
rapid respiration, and corresponding equalization and elevation of 
the temperature of the trunk and extremities, and by suppression 
of the secretions of the mucous membrane of the tonsfue and 

o 

mouth, loss of appetite, derangement of digestion, severe pain in 
the head, and high-colored, strongly acid urine. 

Thinking that it was not only improbable, but impossible, that 
chill and fever could arise in Athens, and failing to infer the con- 
nection of the periodic disturbances with the operation of malaria 



214 



OBSEEVATIONS ON" 



(because, up to the present time, they had never been attended by 
a well-marked chill and febrile excitement), I neglected to use the 
sulphate of quinia. After the intermission of one week, the chill 
and fever returned with increased violence. The free administra- 
tion of the sulphate of quinia after this paroxysm, prevented a 
subsequent return, and, with the disappearance of the chill and 
fever, the headaches vanished, and I have been free from them to 
the present time, one year. 

Several of the students who had resided in malarious districts, 
previous to their residence in Athens, were attacked with inter- 
mittent fever, which, previous to the attack, appeared to have de- 
stroyed, to a considerable extent, the colored blood-corpuscles. I 
examined these cases, and inquired into their previous history 
carefully, and am convinced that they were genuine cases of mala- 
rial fever, induced by the action of a poison which had been re- 
ceived into the system months previous to their residence in this 
healthy climate and locality. The third attack from which I suf- 
fered, was contracted during a visit to the swamps of Georgia, in 
the month of September. Although much more severe than the 
two which I have recorded, the preceding symptoms did not 
differ essentially from those of the first attack, with the exception, 
that there was no affection of the bowels preceding the fever. 

These cases demonstrate conclusively that the malarial poison can exist 
in the system^ and induce slow alterations in the hlood^ without the ap- 
pearance of those phenomena characteristic of fever ^ and without any 
marked aherration of nervous action. 

Many other facts might be brought forward to support this state- 
ment. Thus the serum of the blistered surfaces, in all the stages 
from the beginning to the end of severe cases of malarial fever, has 
always (as far as my observations extend) presented a golden-yel- 
low color. Post-mortem examinations have revealed the fact that 
the livers of those residing in malarious districts have presented the 
peculiar slate and bronze color, although the patients had, at no 
previous time, manifested the phenomena of fever. The spleen of 
a large stout man, who was seized suddenly with coma whilst ex- 
posed to the malarial influence on the Savannah River, and who died 
after forty-three hours' sickness, was enlarged, softened, and of a slate 
color ; the liver was changed to the slate and bronze color in seve- 
ral places, and the bile was concentrated and of a brownish-black 
color, with greenish reflections, and poured like molasses. Under 
the microscope the colored corpuscles of the splenic mud appeared 



MALAKIAL FEVER. 



215 



swollen and altered; the solitary glands of the intestines were en- 
larged ; and the heart contained a fibrous clot. In this case the 
changes were at least simultaneous with the manifest disturbances 
of the physical, chemical, vital, and nervous phenomena. 

Dr. Stevens' ascertained that in the marsh fevers, both of America 
and of the West Indies, the blood is diseased before the attack ; it 
was found to be dark in color, and evidently deranged in its phy- 
sical properties ; its serum, instead of being translucent, presented 
a muddy or brown color, and sometimes an oily appearance. 
During this altered state of the blood, previous to its effects upon 
the nervous system, by which alone the patient would be aware 
that the healthy functions of the body were disturbed, the tem- 
perature of the body would frequently be reduced several degrees 
below the normal standard, and the pulse becomes less frequent. It 
has been asserted that the seasoning fever of the West Indies (en- 
demic yellow fever) is preceded by a morbid condition of the blood. 

Dr. Ch. W. BalP observed that whilst the fainting fever of Persia 
was at its height in Teheran, the blood, even of those not sensibly 
attacked, presented a dark, dusky, reddish-brown color, very dif- 
ferent from that of healthy venous blood ; and that in general the 
serum did not separate from the clot. 

Dr. John Mitchell,^ of Virginia, Salvagnoli, Dr. Archer,'' of N'or- 
folk, and Dr. Porter, of Baltimore, and others, have recorded similar 
observations with reference to the changes of the blood previous 
to the manifestation of aberrated nervous action. 

Dr. Potter,^ in the fever which prevailed in Baltimore in 1800, 
demonstrated this fact conclusively by the following examinations : 
" To ascertain the appearance of the blood in good health, I drew 
it from five persons who had lived, during the whole season, in the 
infected parts of the city, who were in every external appearance 
and inward feeling in perfect health. The appearance of the blood 
could not be distinguished from that of those who labored under 
the most inveterate grades of the disease. A young gentleman 
having returned from the western part of Pennsylvania on the 10th 
of September in good health, I drew a few ounces of blood from a 
vein on that day; it discovered no deviation from that of other 

' Stevens on tlie Blood, pp. 214-219. 

2 British and Foreign Med. Rev., xvi. p. 521.. 

^ Medical and Philos. Register, vol. iv. p. 188. 

4 History of the Yellow Fever of Norfolk in 1821, Med. Recorder, voL v. p. 68. 

5 A Memoir on Contagion, p. 54. 



216 



OBSEEYATIONS ON 



healthy persons. He remained in my family till the 26th of the 
month, and on that day I repeated the bloodletting. The serum 
had assumed a deep yellow hue, and a copious precipitate of red 
globules had fallen to the bottom of the receiving vessel." 



CHAPTEE Y. 

CHANGES OF THE ORGANS, AND TISSUES, AND APPARATUS OF THE BODIES OP 
THOSE WHO HAVE DIED WITH THE DIFFERENT TYPES OF MALARIAL FEVER, 
INTERMITTENT, REMITTENT, AND CONGESTIVE — COMPARISON OF THESE 
CHANGES WITH THE PHENOMENA OF MALARIAL FEVER, AND WITH SIMILAR 
CHANGES IN OTHER DISEASES, AND WITH THE ORGANS, TISSUES, AND AP- 
PARATUS OF MEN AND ANIMALS IN THE NORMAL CONDITION. 

Exterior skin — Muscular system. Head — dura-mater, arachnoid membrane, pia- 
mater, cerebrum, cerebellum, medulla oblongata, ventricles of brain, &c. Nervous 
phenomena of fever, compared with post-mortem examinations. Chest — Lungs, 
heart. Alimentary and intestinal canal — Mouth, tongue, oesophagus, stomach, 
duodenum, jejunum, ileum, colon, rectum, glands of Peyer, solitary glands. 
Liver — Slate and bronze color of liver ; changes of blood of liver ; malarial 
liver contains animal starch, but no hepatic sugar ; bile. Spleen — Slate color of 
spleen ; pulp of spleen ; alterations of structure. Kidneys — Supra-renal cap- 
sules. Bladder. 

The following observations are based upon a careful examination 
and comparison of the symptoms of three hundred cases of malarial 
fever; fifteen post-mortem examinations of the bodies of those who 
had died from the different types of malarial fever, intermittent, 
remittent, and congestive ; numerous examinations of the bodies of 
those who had died from various diseases, as phthisis pulmonalis, 
pneumonia, pleurisy, dysentery, diarrhoea, cirrhosis of the liver, 
fatty degeneration of the liver, dropsy, hemorrhage, apoplexy, can- 
cer, intemperance, scarlet fever, diabetes, Bright's disease, enlarge- 
ment of the lymphatic glands, typhoid fever, and yellow fever, and 
upon the careful dissection and microscopical examination of the 
organs, tissues, and apparatus of several hundred fishes, reptiles, 
birds, and mammalia. 

Exterior. — In the severe cases of malarial fever, which terminate 
in a short time, the muscular system, and the fat surrounding the 
muscles, did not appear reduced to any great extent. In cases of 



MALARIAL FEVER. 



217 



long standing, especially those whicli had been neglected, there was 
great loss of flesh and fat, and the body and limbs presented an 
emaciated appearance, unless the tissues were infiltrated with serum. 
As a general rule the cadaverous rigidity was well marked. 

In many cases the surface presented a sallow hue ; and in one 
violent case of congestive fever, several hours before death, as the 
patient lay in a profound stupor, the whole surface assumed a golden 
yellow color, similar to that of the serum which issued from a blis- 
tered surface over his epigastrium. 

In the majority of cases, the color of the skin of the superior 
parts, after death, presented a pale, bloodless appearance; whilst 
the skin of the inferior (dependent) portions presented a mottled 
purplish color. This dark purplish color of the dependent parts 
gradually diminished towards the superior uppermost parts of the 
body in the recumbent posture, and appeared in every instance to 
have been due to the gradual settling of the blood in the capillaries of 
the most dependent parts towards the close of life, when the general 
and capillary circulations were feeble. For this reason the lips and 
gums were almost always pale, and almost white. The lungs, and 
liver, and kidneys, and intestines, and stomach, and brain in many, 
if not in every case, presented similar evidences of the gradual set- 
tling of the blood in the vessels and capillaries of the most depend- 
ent parts towards the close of life, when the feeble circulation was 
readily overcome by the force of gravitation. If stimulants and 
sinapisms had been freely used in the last hours, the settling of the 
blood in the most dependent parts was not so marked. 

Oerebro- Spinal Nervous System. 

As far as my observations have extended, in malarial fever the 
dura mater was always normal — the arachnoid membrane pearl- 
colored, opalescent in some cases, in others perfectly transparent 
and normal in appearance — the bloodvessels of the pia mater con- 
gested with blood, but always without any marks of inflammation ; 
subarachnoid fluid in almost all cases clear, and transparent, and 
in one or two cases colored by the presence of colored corpuscles ; 
in severe cases of a golden color ; the amount varied in different 
cases, sometimes exceeding, but most generally falling short of the 
usual amount — the bloodvessels of the brain generally filled with 
blood — structures of the brain appeared in almost every case 
normal, altered neither in consistency nor appearance ; blood was 
effused upon the brain in only two instances. 
15 



218 



OBSEEYATIONS OX 



The opalescent pearl color of the arachnoid membrane in spots, 
was of little diagnostic value, because it was by no means uniform. 
In like manner, the variations in the amount of the subarachnoid 
fluid and cerebro-spinal fluid was of little diagnostic value, because 
its chief use is mechanical, and Magendie has shown that it can be 
rapidly secreted and rapidly absorbed without any disturbance of 
the functions of the brain ; and further, that even in the normal 
condition it varies greatly in amount, from two drachms to two 
ounces ; and Cotunnius, the original discoverer of this fluid, states 
that in experiments upon the bodies of twenty adults, the amount 
of this fluid varied from four to five ounces. 

In asserting that the structures of the brain in malarial fever 
were, as a general rule, altered neither in consistence nor in appear- 
ance, we do so only upon the evidence afforded by sight and touch; 
we do therefore by no means affirm this to be a fact established 
"upon an immutable basis. How difficult is it to prove the mode of 
action of the malarial poison upon the nervous system, especially 
when it may act in a manner analogous to that of certain violent 
poisons, which we know will occasion almost instantaneous death, 
without producing a single pathological alteration recognizable by 
the most delicate chemical tests, or the most rigid microscopical 
examination. We know that some substances, as chloroform, will 
produce sudden death, in some cases, where there is no assignable 
cause, either in the structures or forces of the patient, or in the 
pathological alterations produced, or in its accustomed action. 
This peculiar action is said to be due to the idiosyncrasy of the 
patient. May not the fatal action of the malarial poison be due, in 
some cases, to the idiosyncrasy of the patient? The question is, 
What is an idiosyncrasy ? No one has ever demonstrated whether 
these peculiarities of constitution depend upon the physical and 
chemical structures and relations of the solids and fluids, or upon 
the relations of the physical, chemical, vital, nervous, and muscular 
forces, or upon both sets of relations combined. We must admit 
that to determine accurately the alterations of the nervous appa- 
ratus, under the action of various morbific and remedial agents, it 
is absolutely necessary that the structures of the difierent parts of 
the nervous apparatus should be submitted to a rigid chemical and 
microscopical analysis. Kumberless insuperable difficulties lie in 
the way of complete microscopical and chemical analyses. It is 
impossible to obtain the substances for analysis until several hours 
after death, and, in substances so liable to change, important altera- 



MALARIAL FEVER. 



219 



tioDS may take place, even in this short time. It is impossible to 
separate the blood entirely from the nervous elements ; and the 
presence of a varying amount of blood, of varying constitution, 
would of itself be sufficient to vitiate the results of every analysis 
which had for its object the determination of the chemical changes 
induced by a most subtle poison. Notwithstanding this imperfect 
state of pathological science; notwithstanding that we have no 
facts to warrant the assertion that the malarial poison acts prima- 
rily or exclusively upon one system of nerves or the other; we 
should, nevertheless, analyze the phenomena as far as our means of 
analysis extend, and use all the well established facts to the extent 
of their bearing and significance. We will proceed to do this. 

As far as my observations extend, the pathological alterations of 
the structures of the brain and spinal marrow do not correspond to 
the symptoms during life. The most universal phenomenon appears 
to be the stagnation and accumulation of the blood in the blood- 
vessels and capillaries of the brain and pia mater. This accumu- 
lation of the blood in the vessels of the brain and pia mater appears 
to be due neither to inflammation nor to irritation, but simply to a 
stagnation of the blood, similar to the stagnation and accumulation 
of the blood in the vessels of the large organs. 

This view is conclusively sustained by the results of treatment. 
In numerous cases I have seen the wildest delirium calmed, the 
intellect aroused into full vigor from the most profound coma, and 
the most alarming cerebral symptoms vanish under the free use of 
stimulants and sinapisms, with or without the sulphate of quinia. 
When the sulphate of quinia was withheld, the effects of the stimu- 
lants and sinapisms would be but temporary; whilst, when it was 
administered in sufficient quantities, the restoration of the intel- 
lectual functions and the removal of the cerebral symptoms were 
permanent. Now, is this the action of stimulants or of sulphate of 
quinia upon an irritated or inflamed brain? These facts alone 
demonstrate conclusively that the cerehro- spinal system is not the seat of 
irritation or inflammation in malarial fever ^ if we limit irritation and 
inflammation to the meaning universally adopted; and that if irritation 
and inflammation of the cerebrospinal system do arise in the progress of 
malarial fever ^ they are hy no means universal phenomena, dependent 
upon the definite and universal action of the malarial poison. 

To what, then, must we refer the aberrated nervous phenomena 
of malarial fever ? Whilst we cannot answer this question fully 
and absolutely in the present imperfect, undeveloped state of phy- 



220 



OBSEEVATIONS ON 



siology and pathology, we can point out and demonstrate three 
distinct causes : 1st, the alterations of the blood ; 2d, the disturb- 
ances of the general and capillary circulations ; and 3d, the direct 
depressing effects of the malarial poison upon the nervous appa- 
ratus. 

1st. The Altered Blood. — We have shown in the preceding chapter 
that the colored blood-corpuscles are not only greatly and rapidly 
diminished in malarial fever, but that they often lose the saline 
constituents. "We have every reason to believe that the blood- 
corpuscles, taken collectively, perform the offices of an immense 
gland for the elaboration of the materials for the nutrition of the 
muscular and nervous systems. We have further shown that the 
coloring matters of the serum are increased, and the coloring mat- 
ters of the bile retained, in the blood of malarial fever. And I 
shall hereafter show that the constitution of the urine is greatly 
altered in the severest forms of malarial fever, and that some of its 
most important constituents are either not formed at all, or, if 
formed, are not eliminated. We have also shown that the fibrin is 
altered both in quantity and in quality. 

Here, then, we have profound alterations of the blood which must 
induce corresponding disturbances in the muscular and nervous 
systems, and in all the organs and tissues which derive their nutri- 
tion from the blood. Here, then, we have profound alterations in 
the constituents of the blood which must produce corresponding 
disturbances in the general and capillary circulations, and in the 
chemical changes in the capillaries and surrounding tissues upon 
which depend the capillary circulation, and, in fact, the development 
and maintenance of all the forces — physical, muscular, and nervous. 

As a general rule, the general and capillary circulations are 
greatly disturbed in congestive fever. These disturbances are mani- 
fested in the quick, thumping action of the heart, the small, feeble, 
rapid pulse, the panting, full respiration, the want of correspond- 
ence between the temperatures of the trunk and extremities, the 
aberration of the physical, chemical, muscular, and nervous pheno- 
mena, and in the stagnation of the blood in the different organs and 
tissues. The stagnation of the blood in the organs, tissues, and 
apparatus, is due to disturbances in the sympathetic and cerebro- 
spinal system, disturbances in the general circulation, disturbances 
in the quantities and qualities of the constituents of the blood, and 
arrest or perversion of the chemical changes of the capillaries. It 
is well established that the circulation of the blood through the 



MALAEIAL FEVER. 



221 



capillaries depends upon the relations, quantitative and qualitative, 
physical and chemical, of the individual constituents of the blood 
to each other, and to the capillaries and the surrounding tissues, 
and that disturbances of their relations will be attended by arrest 
of the capillary circulation, and stagnation and congestion of the 
blood, notwithstanding that the general circulatory apparatus may 
receive a sufficient supply of nervous force, and perform its offices 
with sufficient vigor. 

When the general circulation is impeded, either by the direct 
action of the malarial poison, or of the altered blood upon the fibres 
of the heart, or by the withdrawal or perversion of the nervous 
force supplied by the sympathetic nervous system, or by the 
cerebro-spinal nervous system, through the sympathetic, conse- 
quent upon the action of the altered blood, or of the malarial 
poison, or of both : it follows, as a necessary consequence, that the 
introduction and distribution of oxygen will be retarded, and the 
chemical changes in the capillaries will be impeded, and the blood 
will stagnate and accumulate in the capillaries. 

"We have before demonstrated that chemical change is necessary 
for the development of muscular and nervous force, and for the 
manifestation of intellectual phenomena. Whenever, therefore, the 
normal chemical actions of the blood are disturbed, aberrated nerv- 
ous action, both in the cerebro-spinal and sympathetic nervous 
systems, must result. 

We have a striking confirmation of these views in the mode of 
origin and progress of the phenomena called chill in malarial fever. 

The poison^ as we have before demonstrated in the chapter on the blood, 
first alters the constitution of the blood, and interferes with the actions and 
secretions of those organs which elaborate the blood, before producing any 
perceptible changes in the phenomena of either the sympathetic or cerebro- 
spinal nervous systems ; this alteration of the blood progresses until a 
point is reached, where either such compounds are generated in the cycle 
of chemical changes, induced by the malarial poison, or the constituents 
of the blood, especially the colored blood- corpuscles and fibrin, become so 
altered that disturbances are produced in the chemical changes by which 
the capillary circulation is maintained, and as a necessary consequence 
the action of the heart, which depends, as all other muscular actions do, 
upon the chemical changes in the capillaries, is impeded, and the blood 
gradually stagnates in the capillaries, and accumulates in the large 
bloodvessels of the trunk and internal organs, and the temperature of the 
extremities, due to the chemical changes of the blood in the capillaries and 



222 



OBSERVATION'S ON 



the surrounding tissues^ sinks far helow the normal standard; this arrest 
of the capillary circulation in the extremities^ and prohahly also in the 
lungs, is attended hy the retention of the products of excretion, as carbonic 
acid, and the matters thrown off from the skin and hidneys ; these excre- 
mentitious offending matters, together with the products resulting from 
the perverted chemical changes, due in part to the reduction of the tem- 
perature of the extremities many degrees helow the normal standard, 
stimulate the sympathetic and cerebrospinal nervous system ; the sensa- 
tion of cold is felt, attended by twitching and jumping of the muscles, 
entirely beyond the control of the will, because they are due to aberrated 
muscular and nervous action, arising from disturbances in the capillary 
circulation, and from the action of the perverted elements of the blood ; 
the respiration is aroused, more oxygen is introduced, and the tempera- 
ture of the trunh elevated, provided the alterations in the constitution of 
the blood have not proceeded too far, or the nervous system been so over- 
ivhelmed, either by the action of the altered products, or of the malarial 
poison, that they cannot respond to the excitation produced by the altered 
and retained productions ; the elevation of the temperature of the trunk 
is attended by a more rapid circulation of the blood in the capillaries of 
the heart and of the nervous centres, and consequently by a more rapid 
and powerful action of the heart and generation of nervous force ; the 
oxygen is introduced and distributed with greater rapidity, the chemical 
changes in the capillaries are again excited, the capillary circulation is 
first restored in the trunk and then in the extremities, the elevation of 
temperature becomes general, and we have the phenomena called fever. 

During the active chemical changes of fever, the malarial poison and 
the altered products of the blood are drawn into the round of chemical 
change, physically and chemically altered, and are finally throivn off 
from the lungs, skin, kidneys, and intestinal canal. After the removal 
of these offending products, the excitants of the sympathetic and cerebro- 
spinal nervous system, after the system has been purified, as if by fire; 
theyi the nervous system returns back to the normal exercise of its func- 
tims ; the force and frequency of the heart diminish; the panting, full 
respiration subsides into the calm regularity of health ; the temperature, 
both in the trunk and in the extremities, returns to the normal standard, 
and we have what is called the remission of fever. 

If remedies have been applied which affect the permanent alteration, 
and destruction, and removal of the malarial poison, there is no return 
of the chill, succeeded by fever. 

If, on the other hand, the poison lias not thus been removed, the same 
round of phenomena is repeated, the blood is again altered, the capil- 



MALAKIAL FEYER. 



223 



lary circulation is again retarded^ and the whole round of phenomena is 
repeated. 

If these views be correct, it is evident that malarial fever is 
paroxysmal, not because the action of the cerebro-spinal or of the 
sympathetic system is paroxysmal, but because the relations of the 
malarial poison to the constituents of the blood and organs and 
apparatuses are such, and the relations to the chemical changes 
necessary to the development of the physical, muscular, and nerv- 
ous forces are such, that a definite series of actions and of chemical 
changes are established, which result in the removal of the offending 
products ; but not always of the primary, disturbing element, the 
poison, which will again excite another round of the same class of 
actions — a paroxysm. 

The theory here advocated is based upon thousands of observa- 
tions upon the pulse, respiration, temperature, physical and chemical 
changes of the solids and fluids during all the stages of fever and 
after death, and is consistent with every fact and observation re- 
corded in this essay. It is important, because it does not call in 
the aid of occult qualities of the nervous system, or the assistance 
of the unknown vis-medicatrix naturse; because it expresses an 
analysis of the phenomena, at the same time that it indicates the 
true principles of the treatment of malarial fever ; and it is espe- 
cially important, because it points out the relative position and 
importance of the phenomena, and the true direction of scientific 
investigation. 

Without multiplying at this time facts, we would simply adduce 
the phenomena of congestive fever, as conclusive demonstration of 
the truth of this theory, or, rather, expression of the relations of 
the phenomena of fever. In congestive fever, where the nervous 
system is overwhelmed, and does not respond to the action of the 
altered compounds, no elevation of temperature is produced, the 
chemical changes are perverted and retarded, and the temperature 
sinks both in the trunk and in the extremities, the altered products 
remain, and death is inevitably the result, unless those remedies 
can be applied which will arouse the sympathetic and cerebro-spinal 
systems; arouse the action of the heart; arouse the chemical 
changes in the capillaries, and lead to a vigorous development of 
the physical, chemical, "muscular, and nervous forces, and result in 
the elimination of the altered products and the poison. 

The following pathological observations will substantiate the 



224 



OBSERVATIONS ON 



assertions, witli reference to the alterations of the nervous struc- 
tures during malarial fever : — 

Case of intermittent fever occurring in the latter stages of phthisis 
pulmonalis. 

When the skullcap was removed, about f^ij of subarachnoid 
and cerebro-spinal fluid, colored red by the blood which escaped 
from the vessels divided during the removal of the skullcap, flowed 
from the base of the brain. 

Dura mater normal. 

Arachnoid membrane slightly opalescent in several spots, espe- 
cially in the neighborhood of the large bloodvessels ; the greater 
part of this membrane, however, was transparent and normal in 
appearance. 

Subarachnoid fluid moderately abundant. 

Bloodvessels of pia mater filled with blood. There were no 
marks of inflammation either in the pia mater or in the arachnoid 
membrane. 

The ventricles of the brain contained sniall quantities of serum. 

The cortical and medullary substances, the cerebellum, pons 
Varolii, the medulla oblongata, and the spinal marrow, appeared 
natural to the naked eye. The structures did not appear to be 
softened or materially altered. 

Case of remittent and typhoid fevers comhined. 

Several days before the fatal termination, the cerebral symptoms 
were well marked. The patient lay in a stupor, with mouth and 
eyes open, and passed his urine and feces in bed ; and it was im- 
possible to arouse him, even by the most violent shaking. The 
examination of the blood, on the day previous to death, showed 
that it had undergone profound alterations. 

Dura-mater perfectly natural; arachnoid membrane opalescent 
(pearl colored) in most parts. There were different degrees of this 
opalescency, from almost perfect transparency to semi-translucency. 
This change was especially evident in the neighborhood of the 
large bloodvessels, and in those portions of the arachnoid which 
covered the depressions between the convolutions. Bloodvessels 
of pia-mater somewhat more distended with blood than usual; but 
not so much, however, as to account for the cerebral symptoms 
during life. Substance of brain firm, and not more congested with 
blood than normal. The appearance of the structure and condition 



MALAEIAL FEVEK. 



225 



of the brain, and its bloodvessels and membranes, did not corre- 
spond to the condition of congestion, effusion, or softening, which 
the cerebral symptoms led ns to expect. The brain was not exa- 
mined microscopically or chemically, and there may have been 
minute chemical and physical changes in its delicate structures, 
which escaped the observation of the naked eye. This is possible, 
but not probable ; for we can hardly suppose that profound altera- 
tions in the structure of so delicate an organ as the brain, without 
some changes in the color or consistence palpable to the naked eye. 
The cerebro-spinal phenomena during life appear to have been the 
result of disturbances in the circulation and constitution of the 
blood, and of the action of the poison or its products in the blood 
upon the ganglionic cells and commissures. 

Case of an Irish haher^ attached during convalescence from remittent 
fever luitJi influenza^ and drowned by the effusion of serum into the 
bronchial tubes and air-cells. 

Dura mater presented the usual appearance; arachnoid mem- 
brane transparent; bloodvessels of pia mater filled with blood. 
"When the dura mater was removed, an ulcer in the substance of 
the brain was discovered, occupying a position near the centre of 
the superior surface of the left hemisphere of the cerebrum. This 
ulcer was three-fourths of an inch in length and half an inch in 
breadth, and about one-eighth of an inch in depth. The walls 
were thickened and much harder than the surrounding brain. The 
bloodvessels of the surrounding pia mater and brain were congested 
with blood, and there was an effusion of a small quantity of bloody 
serum between the arachnoid and pia mater, in the immediate 
neighborhood of the ulcer, but novv^here else. The appearance of 
the ulcer, and the congestion of the bloodvessels around, by no 
means accounted for the death of the patient. The ulcer appeared 
to be of long standing, and was in the process of healing. During 
the attack of malarial fever, and during convalescence, the patient 
was dull, lethargic, and indisposed to exert his mind or body. 
The existence of this ulcer will account for these phenomena, but 
not for the death of the patient, which was due to the rapid pouring 
out of the altered liquor sanguinis of the blood into the air-cells and 
bronchial tubes. The cerebral symptoms after this calamity were 
not different from those which would occur in impeded respiration 
and circulation, when the distribution of the oxygen and the removal 
of the carbonic acid were retarded. The ventricles of the brain 



226 



OBSEEYATIOXS 01s 



contained the usual amount of clear fluid, and the structures of 
the brain presented the usual consistence and appearance. 

Case of Irish lahore'r, attached luWi pleuro-pneumonia^ during conva- 
lescence from remittent fever. 

During the attack of remittent fever, which was severe, the 
cerebral symptoms were absent. During the attack of pleuro- 
pneumonia which supervened immediately upon the remittent 
fever, the cerebral symptoms were well marked ; great excitement 
and frequent aberrations of the intellectual faculties. 

Dura mater healthy ; arachnoid membrane transparent through- 
out its extent over the hemispheres of the brain. At the base of 
the brain it was slightly opalescent. Bloodvessels of pia mater 
not more filled with blood than usual. The cortical and medullary 
substances of the cerebrum and cerebellum, the pons Varolii, the 
medulla oblongata, and superior portion of the spinal marrow, 
appeared natural in consistence and color ; ventricles of the brain 
contained f5iv of golden-colored serum. The superior longitudinal 
sinus of the dura mater contained a golden-yellow elongated clot, 
the diameter of which was about one-half that of the longitudinal 
sinus. 

Case of an Irish laborer^ icho icas attached in the early stages of 
convalescence from intermittent fever ^ icith an eruj^tive disease resemhUng 
the severest form of lichen agrius. 

This patient had been exposed to the malarial influence in a low, 
damp, marshy situation. The eruption was very thick upon the 
face, neck and chest ; in these regions, and especially upon the 
face, the papulae were very numerous, prominent, of a vivid red 
color, and in many places closely aggregated into large clusters, of 
irregular form and size. Kumerous vesicles and pustules, contain- 
ing sero-purulent fluid, were mingled with the papula. From the 
clusters of papula, vesicles and pustules, an ichorous or sero-puru- 
lent fluid issued, and desiccated into yellow crusts. In some places, 
from the thickening of the skin, the density of the crust, and the 
depth of the fissures, the disease might have been mistaken for 
psoriasis. On the legs the eruption was much thinner, and resem- 
bled lichen tropicus (prickly heat). The vesicles and pustules were 
so large and numerous, that across the ward the eruption resembled 
smallpox. Under treatment, the discharge of sero-purulent fluid 
ceased, the pustules and vesicles dried up, and the symptom gra- 



MALAEIAL FEVER. 



227 



dually disappeared, but the patient continued weak and feeble and 
lethargic. Twelve days after his entrance into the hospital with 
the eruption, he was seized with a strong convulsion, which lasted 
about ten minutes, and was succeeded by stupor. Eour hours after 
the convulsion, could not be aroused by the loudest interrogations 
and the most violent shaking. The left arm was drawn across the 
breast, and appeared paralyzed. It required considerable force to 
straighten it, and when released it would fly back to its former 
position, like a steel spring. The left leg was also paralyzed, and 
in like manner returned when removed from its position. The 
patient remained in this state forty-eight hours, and then died. 

When the skullcap was removed, about f^vj of blood flowed 
from the base of the brain. Dura mater normal in appearance; 
arachnoid membrane slightly pearl colored, opalescent in several 
places; bloodvessels of pia mater, especially at the base of the 
brain, filled with blood. Much blood and bloody serum were effused 
between the dura mater and arachnoid membrane. Cerebellum and 
pons Yarolii of a blood-red color upon the exterior. The ventricles 
of the brain were almost entirely filled with serum. The structure 
of the brain appeared to be somewhat softer than usual, and the 
bloodvessels were filled with blood, and distinct. Bloodvessels of 
medulla oblongata and superior portion of spinal cord filled and 
distended with blood. Much bloody serum was effused around the 
spinal cord. No clots were found in the blood and serum effused 
around the brain. The liver and spleen bore the marks of the 
effects of malarial fever; they were, however, recovering. It is 
impossible to determine positively the cause of this sudden effusion 
of blood and serum upon the brain. Were the softening of the 
nervous structures and alterations of the capillaries the results of 
the malarial poison ? or were they the results of the action of the 
cause, whatever it was, which produced the eruption ? 

Case of remittent fever ^ occurring in an Irish halcer^ of feehle consti- 
tution^ during exposure and dissipation. This patient died without 
any treatment, except the administration of a purgative. 

Dura mater and arachnoid membrane normal ; bloodvessels of 
pia mater contained more blood than usual, but there were no 
marks of inflammation ; fsj of clear serous fluid escaped from the 
spaces between the dura mater and arachnoid membrane, and be- 
tween the arachnoid membrane and pia mater. 



228 



OBSEEVATIONS ON 



Case of remittent fever converted into congestive fever ^ hy excessive 
purgation^ and yieglect of stimulation and the sulj^iliate of quinia. 

Towards the close of life the intellect was sluggish, but perfectly 
clear when aroused. Throughout the attack there were no well- 
marked cerebral symptoms. Brain examined twelve hours after death. 

Dura mater unusually thick and firm, and adherent in several 
places to the arachnoid membrane. The thickening of the dura 
mater and the adhesions were of long standing, and were not con- 
nected with this attack of malarial fever. Bloodvessels of the dura 
rnater filled with blood ; arachnoid membrane opalescent, pearl 
colored, and in many places adherent to the pia mater. These 
adhesions, like those between the dura mater and arachnoid mem- 
brane, were apparently of long standing. Between the arachnoid 
membrane and pia mater bloody serum was effused, thus imparting 
to these membranes (especially the inferior portions from the gravi- 
tation of the blood) a red appearance. Bloodvessels of pia mater 
were filled with blood. The bloodvessels of those portions of the 
pia mater which extended into the ventricles of the brain were also 
engorged with blood. The ventricles of the brain contained a small 
quantity of clear serum. Structure of cerebrum appeared to be 
somewhat softer than normal. This softening may have been the 
result of post-mortem decomposition. Bloodvessels in the sub- 
stance of the brain distinct and more engorged with blood than 
usual. Structure of cerebellum, medulla oblongata, and superior 
portion of spinal cord presented the usual appearance and tenacity. 
The bloodvessels of the spinal cord appeared to be more congested 
with blood than usual. 

Case of congestive fever^ aggravated and shortened hy bleeding and 
purgatives^ and allowed to run its course unchecked^ hy the neglect of 
stimulants and sulphate of quinia . 

Before the abstraction of blood the cerebral symptoms were 
urgent. The patient appeared to suffer intense agony in his head ; 
both hands were clasped around his head ; he tossed violently about 
his bed; every breath was accompanied with a deep groan, and 
an exclamation about the pain in his head ; and he was unable to 
give a coherent answer. Cut-cups to the temples and back of the 
neck, general bloodletting, and sinapisms, relieved the cerebral 
symptoms. Stimulants and sulphate of quinia were not adminis- 
tered, and the cerebral symptoms returned with much less violence, 



MALARIAL FEVER. 



229 



and at the end of fifty hours the patient died. When the skullcap 
was removed, four hours after death, f^ij of blood flowed from the 
base of the brain, and appeared to have come, in great measure, 
from a rupture in one of the sinuses of the dura mater. 

Arachnoid membrane opalescent, pearl colored. A small quan- 
tity of yellow serum was effused between the arachnoid membrane 
and pia mater. Bloodvessels of pia mater engorged with blood. 
Substance of brain appeared to be softer than usual. Upon the 
cut surface were seen the cut extremities of numerous bloodvessels 
filled with blood. The lateral ventricles of the brain were nearly 
filled with golden serum. Bloodvessels of that portion of the pia 
mater which enters the ventricles engorged with blood. Blood- 
vessels at the base of the brain and superior portion of the medulla 
oblongata greatly distended with blood. The bloodvessels at the 
base and dependent portions of the brain were more distended with 
blood than those of the superior portions of the brain. There were 
no marks of inflammation anywhere, and the congestion of the 
blood in the bloodvessels appeared to be due to its stagnation from 
disturbances of the general and capillary circulations, produced by 
the altered blood and the formation of heart clots and fibrinous 
concretions in the pulmonary arteries and veins. 

Case of congestive fever ; death resulting, in great measure^ from the 
formation of fibrinous concretions in the heart and bloodvessels. 

The cerebral symptoms appeared suddenly, and were of the most 
marked and decided character. The patient was taken suddenly 
with coma, and lay with his mouth and eyes open, perfectly insen- 
sible, and emitting at every breath a sharp, quick groan, like the 
barking of a dog. When the skullcap was removed, three hours 
after death., f|iij of bloody serum flowed from the base of the brain. 
The admixture of blood with the cerebro-spinal fluid appeared to 
have been due entirely to the wounding of bloodvessels during the 
removal of the skullcap. The arachnoid membrane was but slightly 
opalescent; in most places it was perfectly transparent. The fluid 
effused between the arachnoid membrane and pia mater, and into 
the ventricles of the brain, presented the golden color of the serum 
of the blood. Bloodvessels of pia mater filled with blood. Blood- 
vessels at the base of the brain, and upon the medulla oblongata and 
spinal cord, more engorged with blood than those upon the superior 
portions of the brain. This was, without doubt, due solely to the 



230 



OBSEEVATIOXS ON 



effect of gravity. The substance of the brain possessed the usual 
consistency, and appeared to the naked eye to be normal in struc- 
ture. 

Case of congestive fever. 

Stout seaman, sick only four days. On the second day became 
comatose, and continued insensible, passing his urine and feces in 
bed until death. The treatment was defective in energy. Stimu- 
lants and sulphate of quinia were not used with sufficient freedom 
and frequency. Brain examined twenty hours after death. 

Dura mater and arachnoid membrane presented a healthy appear- 
ance. The subarachnoid fluid was of a reddish color. The ventri- 
cles of the brain were almost completely filled with a reddish fluid. 
Bloodvessels of pia mater congested with blood. Bloodvessels of 
the superior portions of the brain less congested wath blood than 
those of the inferior portions. The substance of the brain pre- 
sented nothing abnormal to the naked eye, or to the touch. 

Case of remittent fever^ neglected for ten days^ terminating in conges- 
tive fever. 

Four days before death cerebral symptoms well marked ; great 
torpor of the intellect when stimulants were withheld, and when 
freely administered unusual excitement, attended with aberration 
and incoherency. Brain examined tiveJve hours after death. 

Dara mater normal; arachnoid membrane opalescent, pearl colored 
in many spots; subarachnoid fluid in normal quantity; bloodvessels 
of pia mater filled with blood ; substance of brain firm., and altered 
neither in consistency nor in appearance. Bloodvessels of the sub- 
stance of the brain not more distinct than normal; ventricles of 
brain, and the space around the medulla oblongata and spinal cord, 
filled with light yellow fluid. When the medulla oblongata, and 
superior portion of the spinal cord were removed, the serum flowed 
in (the shoulders being slightly depressed), and filled the vertebral 
canal. 

Case of congestive fever ; fibrinous concretion in the heart and Hood- 
vessels^ cerebral symptoms severe^ coma^ and complete insensibility. 
Brain examined ticelve hours after death. 

The longitudinal sinus of the dura mater contained an elongated, 
flattened, ribbon-like, fibrinous clot, which was free from colored 
blood-corpuscles, and of a light yellow color. This was, without 



MALAEIAL FEVER. 



231 



doubt, formed before death. Arachnoid membrane opalescent, pearl 
colored in many places. Bloodvessels of pia mater filled with blood. 
Substance of brain appeared to be normal in color and texture, as 
far as an examination with the naked eye extended ; it was, per- 
haps, a little softer than usual; but this may have been due to post- 
mortem changes, and at any rate would not account for the symp- 
toms during life. Bloodvessels of medulla oblongata and superior 
portion of spinal cord not congested with blood. 

Case of congestive fever. Death occurred forty -three hours after the 
commencement of the attach^ which commenced suddenly^ with vomiting^ 
cold extremities^ complete prostration^ and delirium. 

When the skullcap was removed, twenty-four hours after death^ 
f^iij blood flowed from the base of the brain, which contained no 
coagula, and appeared to have been effused before death. Arachnoid 
membrane opalescent in a fev/ spots. Bloodvessels of pia mater 
filled with blood. The sub-arachnoid fluid was of a bloody red 
color. Bloodvessels at the base of the brain, and surrounding the 
medulla oblongata and superior portion of the spinal cord, were 
filled with blood. The substance of the brain was normal in con- 
sistence and appearance. 

Chest. 

The lungs^ in uncomplicated malarial fever, presented no abnor- 
mal appearance, except the accumulation of the blood in the most 
dependent parts, which resembled in all respects and were due to 
the same causes as the accumulation of the blood in the vessels of 
the most dependent parts of all the organs and tissues. 

The heart presented no uniform pathological alterations which 
could be referred to malarial fever. In the hearts of drunkards, 
fatty degeneration was frequently observed ; but this was an effect 
of the alcohol, and not of the malarial poison. In some cases the 
heart was paler and softer than usual ; these did not appear to be 
uniform alterations. 

Alimentary Canal. 

During the severe forms of malarial fever, the secretions of the 
mouth were, as an almost universal rule, suppressed; and the 
tongue, when not coated with fur, presented a bright red, dry, 
rough surface, with enlarged papillse. The bright red color of the 
tongue was due to the stagnation of the blood and the accumulation 



232 



OBSEEYATIOXS ON" 



of the blood-corpuscles in the capillaries. In numerous instances 
I have observed the dry, harsh, hard tongue become soft and moist 
under the action of stimulants and sulphate of quinia. This sup- 
pression of secretion and congestion of the bloodvessels of the 
tongue and mucous membrane of the mouth, was the result of de- 
rangements in the capillary circulation, induced by altered blood, 
by the disturbed circulation, and by aberrated nervous force sup- 
plied by the sympathetic S3^stem, and not of inflammation or irrita- 
tion. We consider the glowing, red, dry tongue of remittent and con- 
gestive fever as a valuable index of the condition of the capillary circu- 
lation in other ^^or/s of the hody. It does not hy any means indicate an 
inflamed or even irritated state of the stomach. In several cases, which 
presented throughout their course dry, red tongues, as hard and as 
rough as boards, attended with great tenderness of the epigastrium, 
the stomach presented after death a normal appearance, without any 
marks of inflammation, or even of irritation. 

STOMACH AND INTESTINAL CANAL. 

The pathological alterations of the stomach, observed after death, 
did not correspond to the severity of the symptoms, the vomiting, 
and pain upon pressure, during the progress of the fever. The in- 
jection of the bloodvessels, and the mottled, purplish, brownish-red 
color after death, appeared to be indicative, not of inflammation, 
but rather of stagnation and accumulation of the blood in the capil- 
laries, consequent upon the disturbance of the relations of the blood 
to the capillaries. The distressing vomiting, so often a troublesome 
symptom in malarial fever, appeared to depend upon the contact of 
the altered bile (the stomach was frequently found discolored with 
bile), and the irritation of the nervous centres which supply the 
stomach with nervous force by the altered blood and by the 
malarial poison. 

In cases where there has been chronic inflammation of the 
stomach before the appearance of the fever, and in cases of long 
standing, where the solids and fluids were permanently altered, 
decided alterations of structure were found in the stomach. It may 
be asserted, however, that there is no constant and characteristic 
leMon of the stomach in malarial fever, which would distinguish it 
from other fevers. 

These remarks apply also to the small intestines. The mucous 
membrane frequently presented a purplish, irregularly injected, 
mottled appearance, especially after the administration of purga- 



MALARIAL FEYER. 



233 



tives; and it was frequently observed that the injection of the 
bloodvessels was greatest in the dependent portions of the intes- 
tines. In several cases, Brunner's glands in the duodenum were 
enlarged and distinct. The solitary glands of the small intestines 
appeared in many cases enlarged and distinct. Peyer's glands, in 
all the cases except one which was characterized by true typhoid 
symptoms, were uniformly free from any well-marked morbid altera- 
tion. In some cases they were distinct and well defined in their 
outline, and presented a honey-comb surface dotted with dark 
points; but they were always free from marks of inflammation, and 
even of irritation, and in their pale white color contrasted strongly 
with the surrounding mucous membranes, discolored with bile, 
and often irregularly injected with blood. 

These statements will now be illustrated by the following post- 
mortem examinations : — 

Case of intermittent fever occurring in the latter stages of phthisis 
piilmonalis. Autopsy twelve hours after death. 

Stomach small, contracted; small intestines and colon inflated 
with air. Mucous membrane of stomach of a purplish-red color in 
spots, presenting a mottled appearance. Bloodvessels upon the 
exterior filled with blood. The small intestines contained fecal 
matters colored by bile. Mucous membrane of the small intestines 
of a dark-purplish and reddish-yellow hue. Bloodvessels upon the 
exterior and through the structures of the intestines were filled 
with dark blood. Glands of Peyer normal, not enlarged nor con- 
gested. Brunner's glands did not attract attention. 

Case of remittent and typhoid fevers combined. Autopsy four hours 
after death. 

Internal surface of the stomach, colored yellow with bile. As 
far as the unaided eye could ascertain, the mucous membrane was 
continuous and unaltered in structure. The bloodvessels of the 
mucous membrane were filled with blood, and several spots were 
more engorged with blood than the rest of the surface, presenting 
an ecchymosed appearance. The mere stagnation of the blood in 
the vessels and capillaries of the mucous membrane is not signifi- 
cant of alterations in the structures, or of inflammation, or even of 
irritation. To the naked eye there were no pathological alterations 
in the structures of the stomach. 

The color of the intestines, externally and internally, was darker 
16 



234 



OBSEEVATIONS ON 



than usual ; the small intestines contained fecal matters, epithelial 
cells, mucus-corpuscles, and mucus colored yellow with bile. Blood- 
vessels of the mucous membrane of the small and large intestines 
injected with blood. The mucous membrane was most injected 
with blood, and presented a purplish color, in the last eight feet of 
the inferior portion of the ileum. This engorgement of the blood- 
vessels was greatest in the immediate region of the ileo-csecal valve. 
The solitary glands were numerous, enlarged, elevated and dis- 
tinct, and of a brown color. When the intestines were held up to 
the light, bloodvessels engorged with blood, were seen passing to 
each gland. The bloodvessels supplying the solitary and Peyer's 
glands were more engorged with blood than those supplying the 
mucous membrane generally. These solitary glands were most 
numerous in the neighborhood of the ileo-caecal valve, and were 
found scattered over the superior portion of the colon ; and over 
the caecum, and over eight feet of the inferior portion of the ileum. 

Peyer's glands were enlarged and elevated. These glands were 
of various sizes, from one-quarter of an inch to half an inch in 
breadth. They occurred at intervals of from one to two inches 
from each other, and extended from the ileo-csscal valve, along the 
mucous membrane of the ileum, for about nine feet. The blood- 
vessels around these glands were engorged with blood. This part 
of the mucous membrane of the ileum, studded with the solitary 
and Peyer's glands, was far more injected with blood than the sto- 
mach, jejunum, or superior portion of the ileum. Although these 
glands were enlarged, elevated, and injected with blood, still they 
could not, by any means be compared to the condition of these 
glands, in an advanced stage of typhoid fever. 

That this case was one of typhoid fever was demonstrated by 
the great susceptibility of the intestinal canal to the action of small 
doses of purgatives, the continued elevation of the temperature, 
and rapid action of the pulse without any remission, the appear- 
ance of albumen in the urine, and the low muttering delirium ; 
that it was also a case of remittent fever was demonstrated by the 
slate or bronzed liver, the alteration in the blood, and the disor- 
ganized enlarged spleen. 

Case of an Irish haJcer^ attached during convalescence from remittent 
fever^ with influenza^ and drowned hy the effusion of serum into the 
bronchial tubes and air-cells. Autopsy eight hours after death. 

Stomach, pale and perfectly healthy in appearance. Intestinal 
canal, from the stomach to the anus, pale and healthy in appearance. 



MALARIAL FEVER. 



235 



Case of Irish laborer^ attached with pleuro-pneumonia during con- 
valescence from remittent fever. Autopsy 7iine hours after death. 

Stomach enormously distended with gas. Mucous membrane pale 
and healthy in appearance. Small intestines and colon healthy in 
appearance to the naked eye. 

Case of an Irish lahorer who was attached in the early stages of con- 
valescence from intermittent fever ^ with an eruptive disease resembling 
the severest form of lichen agrius, and who died suddenly from effusion 
of blood u/pon the base of the brain. Autopsy five hours after death. 

Bloodvessels upon the exterior of the stomach filled with black 
blood. Internal mucous membrane generally of a reddish and 
pinkish color, and in many spots where the congestion was greater, 
the color was much deeper. Brunners glands in the duodenum, 
and Lieberkiihn's follicles, in the pyloric extremity of the stomach, 
and in the pylorus and duodenum, appeared to be enlarged, and 
gave to the mucous membrane a mammillated appearance. 

Mucous membrane of the small intestines of a reddish color, with 
bloodvessels filled with blood, especially at the superior portion. 
The glands of Peyer, in the inferior portion of the ileum, espe- 
cially in the region of the ileo-csecal valve, were enlarged. Solitary 
glands in the superior portion of the colon also enlarged. Mucous 
membrane of the stomach and intestines was colored yellow by the 
bile. The small intestines contained much offensive gas, tenacious 
mucus, and fecal matters colored yellow by the bile. The colon 
was distended with offensive gas. 

Case of a house painter^ luho during convalescence from a severe 
attach of malarial fever luas seized vnth convulsions^ and died comatose. 
Autopsy five hours after death. 

Stomach and small and large intestines presented a healthy ap- 
pearance. 

Case of German butcher^ who^ after suffering with chill and fever for 
two months without any medical attendance^ was seized with congestive 
fever. Autopsy four hours after death. 

He was relieved from congestive fever, but the alterations of the 
organs and tissues and blood had been so profound, that notwith- 
standing the use of alteratives, sulphate of quinia, stimulants, and 
nutritious diet, he died twenty-three days after the attack of con- 
gestive fever. Previous to death the digestion was imperfect and 
the bowels loose. 



286 



OBSERVATIONS OX 



The stomach and small and large intestines were greatly con- 
tracted. Bloodvessels of mesentery, omentum, and exterior surface 
of stomach, and small and large intestines, engorged with black 
blood. The mucous membrane of the stomach presented an ap- 
pearance resembling that of chronic inflammation. The exterior 
of the large and small intestines was of a purplish color. The 
mucous membrane of the small intestines did not appear to be 
altered in structure. • Glands of Peyer, enlarged and distinct; some 
of them were several inches in length. The glands of Peyer, how- 
ever, did not present the appearance of active inflammation, as in 
typhoid fever. They were even paler than usual. The solitary 
glands did not attract attention. The lymphatics of the mesentery 
were much enlarged. 

It is worthy of note that in this case, which assumed a low ty- 
phoid type, the glands of Peyer were not inflamed. 

Case of remittent feve'i\ occurring in an Irish laborer of feehle consti- 
tution^ during exposure and dissijjation. This patient died icithout any 
treatment except the administration of a gentle purgative. Autcpsy four 
hours after death. 

The mucous membrane of the stomach presented the usual 
healthy appearance. The mucous membrane of the small intes- 
tines appeared to be healthy. Glands of Peyer large and distinct, 
but pale, and without any marks of congestion or inflammation. 
Several of these glands were three inches in length. The solitary 
glands, especially in the region of the ileo cecal valve, were en- 
larged and prominent. They were about the size of millet-seed, 
and of a reddish-brown color. 

Case of remittent fever^ converted into congestive fever hy excessive 
purgation and. neglect of stimulation and. the sulpliate of cpj.inia. Au- 
topsy twelve hours after death. 

The stomach contained no fluid or gas; bloodvessels upon the 
exterior filled with blood ; mucous membrane of stomach of a 
dark purplish color. The color of the mucous membrane was not 
uniform; it was much deeper in some spots than in others, thus 
presenting a mottled appearance. The compound muciparous fol- 
licles (Brunner's glands) of the stomach and duodenum were pro- 
minent and enlarged. 

Bloodvessels of the superior and inferior portions of the intes- 
tinal canal appeared to be more engorged with blood than those of 



MALAEIAL FEVER. 



237 



the middle portions. The mucous membrane of the small intestines 
was covered by a layer of mucus and fecal matter, colored yellow 
by the bile. 

The solitary glands in the inferior portion of the ileum, and 
especially in the region of the ileo-c«cal valve, were enlarged and 
distinct. The glands of Peyer were distinct, but not enlarged or 
inflamed. 

Case of congestive fever^ aggravated and shortened hy Heeding and 
purgatives^ and allowed to run its course ujichecked^ hy the neglect of 
stimulants and sulphate of quinia. Autopsy four hours after death. 

Mucous membrane of stomach corrugated and of a purplish 
color, varying in intensity in different spots. The stomach con- 
tained eight fluidounces of a dark greenish-black fluid, which re- 
sembled, upon a general view, the black vomit of yellow fever. 
Under the microscope this fluid was found to contain numerous 
mucus-corpuscles, epithelial cells of the mucous membrane, and 
gastric glands, peptic cells, and dark granules. These various, 
bodies were of a greenish and yellow color under the microscope. 
The action of nitric acid demonstrated that the color was due to 
the presence of bile. The color of a mass of this fluid from the 
stomach, like that of the bile from the gall-bladder, was of a dark 
blackish-green color, whilst the thin layers, like those of the bile, 
were of a yellow color. I was unable to distinguish any colored 
corpuscles, notwithstanding the close resemblance to black vomit. 
The granules did not resemble altered blood-corpuscles. 

The color of the mucous membrane of the small intestines was 
darker than usual, and the surface was covered with mucus-cor- 
puscles and epithelium, colored yellow by bile. 

Bloodvessels of the ileum, especially in the region of the ileo- 
cecal valve, engorged with blood. Neither the glands of Peyer 
nor the solitary glands were enlarged. Bloodvessels of colon filled 
with blood. Exterior surface of rectum diversified by numerous 
ecchymosed spots of a bright arterial hue. 

Case of congestive fever. Death resulting in great measure from the 
formation of fibrinous coagula in the heart and bloodvessels. Great 
tenderness upon pressure of epigastrium. Aut-opsy three hours after 
death. 

Stomach distended with gas. Mucous membrane discolored by 



238 



OBSERVATIONS ON 



yellow bile, and diversified with punctated spots of a brilliant red 
color. 

Small intestines contained bile and feces, which were extraordi- 
narily offensive. The calomel and oil administered previous to 
death had commenced to operate. When the feces and epithelial 
cells, colored yellow by bile, were scraped off, the mucous mem- 
brane presented the normal appearance. The glands of Peyer were 
remarkably large and distinct; several of them were three inches 
in length ; their surfaces were pale, and exhibited no marks of 
inflammation. 

Case of congestive fever. Stout seaman^ sich only four days. On 
the second day hecame comatose^ and continued insensible^ passing Ms 
urine and feces in hed until death. Autopsy twenty hours after death. 

The raucous membrane of the alimentary canal, from the oeso- 
phagus to the anus, presented the normal color, and showed no 
signs whatever of congestion or inflammation. 

Case of remittent fever^ neglected for ten days, terminating in conges- 
tive fever. Tongue red^ dry^ and hard. Autopsy twelve hours after 
death. 

Bloodvessels upon the exterior of the stomach filled with blood. 
The mucous membrane bore no marks of inflammation, and was 
not more congested with blood than usual. 

The exterior and mucous membrane of the jejunum presented 
the usual appearance. There was no unusual appearance, either of 
congestion, irritation, or inflammation. The mucous m^embrane of 
the ileum, especially at the lower portion, was more congested with 
blood, and of a darker color than usual. The intestinal canal, 
through its entire length, was empty. The mucous membrane 
presented a yellow appearance, probably due to the presence of 
bile. 

The solitary glands of the ileum, especially in the neighborhood 
of the ileo-csecal valve, were numerous, enlarged, elevated, distinct, 
and of a brown color. When the intestines were held up to the 
light, the bloodvessels filled with blood could be distinctly seen 
sending off branches to each gland. The glands of Peyer were 
large, distinct, and elevated. Several of these glands in the lower 
portion of the ileum were three inches in length. These glands, 
however, were not inflamed, as in typhoid fever, and presented the 
usual pale appearance. 



MALARIAL FEVER. 239 

Case of congestive fever. Fibrinous concretions in the heart and 
hloodvessels ; cerebral symptoms severe ; coma and complete insensibility ; 
tongue red, dry^ rough, and hard. Autopsy twelve hours after death. 

Exterior surface of stomach and intestines pale. Bloodvessels 
of omentum and mesentery were filled with black blood. The 
stomach contained a yellow, mucus-like fluid. The mucous mem- 
brane of the stomach was dyed yellow by the bile. A¥ith the 
exception of this discoloration, the mucous membrane of the sto- 
mach appeared to be normal. There were no marks of inflamma- 
tion. The small intestines contained large quantities of yellow 
mucoid matter, mixed with soft fecal matters. When carefully and 
completely washed under a gentle stream of water, the free edges 
of the valvulse conniventes presented a bright red and bistre color, 
which diminished in intensity towards the attached portion. The 
whole surface of the mucous membrane of the small and large in- 
testines was of a darker color, and indicated much more congestion 
than usual. I do not consider the congestion of the bloodvessels 
of the mucous membrane as a pathological alteration, due either to 
the primary or secondary effects of the malarial poison, because at 
the time of his death the patient was under the action of a cathartic. 
Cathartics, as far as my experiments upon animals have extended, 
produce engorgement of the vessels of the mucous membrane of 
the intestines. Glands of Peyer and solitary glands not enlarged 
or inflamed. 

Case of congestive fever. Death occurring forty-three hours after the 
commencement of the disease^ which was ushered in suddenly with vomit- 
in g^ CO Id extremities^ comp lete prostration^ and delirium. Autopsy twenty - 
four hours after death. 

The mucous membrane of the stomach presented two well-defined 
portions; the mucous membrane of the lesser curvature of the 
stomach was pale and normal in appearance; the mucous mem- 
brane of the greater curvature and pyloric extremity, and of the 
pylorus, was of a purplish color, and ecchymosed in crimson spots. 
The bloodvessels of the greater curvature and of the pylorus were 
congested with blood. Mucous membrane of the superior portion 
of the jejunum congested with blood; valvulse conniventes, espe- 
cially at the edges, ecchymosed in spots, of a purple and scarlet 
color. Mucous membrane of the lower portion of the ileum greatly 
congested with blood. Peyer's glands somewhat enlarged, more 
distinct and elevated than usual, but pale and not congested and 



240 



OBSERVATIOXS ON 



inflamed as in typhoid fever. Solitary glands enlarged and distinct. 
Mucous membrane of colon greatly congested with blood. 

Liver. 

The size of this organ, the complexity and delicacy of its struc- 
tures, and the extent and variety and importance of its offices, all 
demonstrate the value and necessity of careful microscopical and 
chemical examinations of its structures, blood and products, in 
pathological conditions. The necessity of these careful examina- 
tions is placed in a stronger and clearer light every time that the 
bounds of pathological and physiological science are enlarged. 

Modern research has confirmed the ancient idea that the liver is 
the fabricator of the blood. M. CI. Bernard^ has demonstrated that 
the liver is a great starch and sugar manufactory, that it possesses 
the power of converting cane sugar into hepatic sugar, and of 
changing the albuminose received from the alimentary canal 
through the portal circulation, into the albumen of the blood. 

Weber^ has shown that there is an extensive generation of 
colored blood-corpuscles in the liver of the embryo, and in the 
liver of the frog in the spring of the year, when the sexual organs 
are highly developed, and when the lymphatic system is in a highly 
active state. 

Kolliker^ and Bernard'' have confirmed these observations, and it 
is now known that there are both a destruction and a regeneration 
and formation of the colored and colorless corpuscles in the liver. 

Thackrah, Simon, Lehman and Bernard have shown that the 
fibrin is altered both in quantity and quality, during its passage 
through the liver. 

According to Simon and Lehmann, the fats are diminished in the 
blood passing through the liver. 

The extractive matters, according to several observers, are in- 
creased in hepatic blood, whilst the albumen, salts, and iron are 
diminished. 

These facts, and many others as well established, indicate that 
the complete examination of the liver in physiological and patho- 
logical conditions, requires a careful analysis and comparison of 

1 "Lectures on the Function of the Liver," L'Union Medicale, 1850. 

2 Henle and Pfeufer's Zeitschrift, 1846. 

2 Kolliker iiber die Blutkorperchen der Menscliliclien Embrvo und die Entwick- 
elung der Blutkorperchen der Saggethieren. 

^ Bernard and Robin on the Blood; translated bj W. T. Atlee, M. D., Pbilada. 
1854, p. 106. 



MALARIAL FEYER. 



241 



the blood in the portal system before its entrance into the liver, 
and of that in hepatic veins, which has traversed the liver — 
requires a careful analysis of the venous blood in other parts of 
the system, and a comparison of the venous, portal, and hepatic 
blood — requires a careful chemical analysis, quantitative and quali- 
tative, of the starch and sugar and bile and other matters separated 
or elaborated from the blood by the liver — requires a complete 
chemical analysis of the contents of the capillaries, and of the 
biliary tubes and cells, and of the walls of these capillaries, tubes 
and cells — requires a complete microscopical examination of all the 
structures of the liver. Not even one single division of these sepa- 
rate subjects of inquiry can, in the present state of phj^siological 
and pathological science, be executed with absolute accuracy, and 
the majority are so complex and difficult of investigation, that 
even the attempt has never been made. 

Besides the difficulties necessarily attending the procuring of the 
blood from the portal and hepatic veins; the value of the analyses 
must be in a great measure vitiated, and the conclusions based upon 
them rendered doubtful in the extreme, by the changes in the cir- 
culation and in the chemical constitution of the blood during the 
last moments, independent entirely of the original changes resulting 
from the action of the poison. 

The difficulty of correct microscopical examination of the liver, 
is strikingly shown by the differences of opinion amongst the most 
distinguished anatomists, with reference to the connection of the 
liver-cells with the hepatic ducts. 

Kiernan,^ Schroder Yander Kolk,^ Krukenberg,' Weber," Ket- 
zius,^ Theile,^ Backer,' Leidy,^ and Beale,^ have advocated the 

^ " The Anatomy and Physiology of the Liver," by Francis Kiernan, Philoso- 
phical Transactions, 1833. 

2 In Backer's Essay, "De Structura Subtilori Hepatis Sani et Morbosi." 

* Gerlach's Gewebelhre, ii. Auflage, p. 329. Untersuchungen ueber den feineren 
Bau der Menschichen Leber, in Miill. Archiv., st. 318. 

* Annot. Anat. et Physiolog., prol. vi., vii., viii., Lips. Zusatze zu seinen Un- 
tersuchungen iiber den Bau der Leber in Berichte der K. Sachs. Ger. d. Wissench 
zu Leipzig, st. 151. Programmatar Collecta, Fasc. ii. Lips. 

^ Uber den Bau der Leber, Miill. Archiv. ii. p. 141. 

6 Art. Leber, in R. Wagner's Handw. der Phys. ii. st. 308. 

' De Structura Subtiliori Hepatis Sani et Morbosi, Dis Inaug. Trajecti ad 
Ehenum. 

^ " Researches into the Comparative Structure of the Liver," by Joseph Leidy, 
American Journal of the Medical Sciences, January, 1848, p. 18. 

9 On Some Points in the Anatomy of the Liver of Man and Vertebrate Animals, 
by Lionel S. Beale, M. D. London, 1856. 



242 



OBSEEYATIOXS 0^- 



existence of a tubular basement membrane, continuous with the 
ducts, within which lie the liver-cells. 

Kolliker' describes the hepatic cells as so arranged in the lobules 
as to form a network, by the simple apposition of the flat surfaces^ 
without the assistance of any foreign connecting, intermediate, or 
investing coat. Isot a trace of biliary ducts is to be observed in 
this network, and it is impossible to make out any connection be- 
tween the biliary ducts and hepatic-cell network, which is undoubt- 
edly the secreting portion of the liver. 

Dr. Handfield Jones^ asserts that the ducts terminate in blind 
extremities on reaching the lobule, instead of forming a plexus 
within it, and that the chief agents in the secretion of the bile are 
the cells lining these ducts, and not the cells lining the lobular 
substance. 

Dr. H. D. Schmidt,^ of Philadelphia, one of the latest and most 
accurate observers on the minute anatomy of the liver, states as the 
results of his observations upon fresh and injected livers, that " two 
capillary networks, each independent of the other, exist in the 
lobule of the liver; the one, commencing at the periphery of the 
lobule, from the smallest branches of the portal vein and hepatic 
artery, and ending in the centre in those of the hepatic vein, is 
destined for the circulation of the blood brought there by the portal 
vein and hepatic artery; the other, commencing independently in 
the centre of the lobule, near the intralobular vein (branch of the 
hepatic vein), and ending in the smallest branches of the hepatic 
duct, is most probably destined to carry off the secretion of the 
cells. The cells lie within the meshes of these two networks ; but 
seem to be especially held in their position b}^ their adhesion to 
the network destined to secretion." 

These facts show the necessity for careful and laborious research, 
and the importance of having a large number of careful, conscien- 

^ Manual of Human Microscopical Anatomy, br A. Kolliker. Translated bv Gr. 
Busk and T. Huxley. Philadelpliia, 1S54, p. 532 et seg. 

2 C. Handfield Jones. ''On the Secretory Apparatus of tbe Liyer;" Pbilosopliical 
Transactions, 1S46, p. 473. " On tlie Structure and Deyelopment of the Liyer ;" 
Phil. Trans., 1849, 1. p. 109. "Further Inquiries on the Structure, Deyelopment, 
and Functions of the Liyer;" Phil. Trans., 1853, part i. pp. 1-29. 

^ American Journal of the Medical Sciences, .Jan., 1859, yol. xxxyii.,N. S.,p. 22. 
In this article Dr. Schmidt describes yaluable apparatus for microscopical inyesti- 
gation, inyented and constructed by himself. The use of such delicate and accu- 
rate apparatus will, without doubt, greatly facilitate and add much accuracy to 
microscopical examinations of the liyer. 



MALAEIAL FEVER. 



243 



tious investigators engaged in this field. The accuracy and value 
of pathological investigation depend upon the state of anatomy 
and physiology. If anatomists and physiologists are not agreed 
with, reference to the minute anatomy of the liver, and the mode of 
formation and offices of its secretions, how can the pathologist 
arrive at accurate and definite conclusions when he has to investi- 
gate not only the complex anatomical structures and secretions, 
but also examine the morbid, physical, and chemical alterations, 
and if possible discover the character and mode of action of the 
morbific agent or agents? 

Notwithstanding that much time and labor were expended in 
microscopical and chemical examinations of the liver in malarial 
fever, yellow fever, and in other diseases ; and notwithstanding that 
several facts, which appear to possess some pathological value, were 
discovered ; still, the knowledge thus far acquired extends only to 
the most general and superficial phenomena, and the whole subject 
is open for investigation, and presents to investigators an inviting 
and almost entirely new and untrodden field. The imperfect results 
of my labors are now presented with the hope that others of far 
more learning and ability may be excited to enter the same field, 
and not only prove the truth or falsity of the observations recorded, 
but also remove the obscurity and absolute ignorance which now 
exist with reference to the cause and character of the pathological 
changes of all the organs, and establish such a body of scientific 
facts as shall lead to the careful determination of the pathological 
alterations and relations of all diseases. 



Weight of the Liver in Malarial Fever. 



Weight of healthy liver ; mean of 82 obser- 
vations on males 

Ditto ; mean of 36 observations on females 

Weight of liver in intermittent fever 

" remittent and typhoid 

fevers 

" lichen agrius during con- 

valescence from remit- 





tent fever . 




5 " 


3 


(( 


remittent fever 




4 " 


3 


il 


congestive fever . 




5 " 


0 


<( 


congestive fever . 




5 " 


3 


(I 


congestive fever . 




4 " 


3i 



Avoirdupois 
pounds. 



I 3 to 4 

3 to 4 
3 lbs. 4 J ozs. 
3 lbs. 11^ ozs. 



Avoirdupois 
ounces. 



48-58 

40-50 
52J 
59J 



83 
67 
80 
83 
671 



Troy 
grains. 



13000 

to 
25375 
17500 

to 
21875 
22968 

25642 



36312 
29312 
35000 
36312 
29416 



OBSEEVATIONS ON" 



According to the researches of Dr. John Reid, the liver weighed 
in 43 cases oat of 82 between 48 and 58 ounces in the adult male; 
and in 17 cases out of 36 its weight in the adult female ranged 
between 40 and 50 ounces. 

It may, then, in general terms be stated that the v/eight of the 
liver in health varies from three to four pounds, according to the 
quantity of blood which it may contain at the time it is examined. 

The comparison of these results with the weight of the liver in 
the different forms of malarial fever, shows that the weight of the 
liver is increased in malarial fever. 

We would naturally expect this increase of weight from the 
stagnation and accumulation of blood in the capillaries and blood- 
vessels of the liver in malarial fever. In all such examinations it 
should ever be remembered that the weight of the liver varies con- 
siderably in health, according to the amount of blood which it 
contains. 

Color of the Liver in Malarial Fever. 

My observations upon the color of the liver, agree in the main 
with those of Dr. Thomas Stewardson,^ of Philadelphia. 

This distinguished pathologist first pointed out the fact that the 
color of the liver in malarial fever is changed from the normal 
reddish-brown to a slaty or bronze, or mixture of bronze and olive. 
The knowledge of this peculiar change of the color of the liver 
during malarial fever is exceedingly valuable as a means of dis- 
tinguishing malarial fever from yellow, typhoid, typhus, and all 
other fevers. 

The observations of Dr. Thomas Stewardson, have been con- 
firmed by those of Dr. Wm. T. Howard,^ in the Baltimore Alms- 
house, of Dr. Swett,^ in the New York Hospital, of Drs. Anderson'' 
and Frick, in the Baltimore Almshouse and Infirmary, and of 
Dr. Richard Arnold,^ in the Savannah Marine Hospital and Poor 
House. 

' Stewardson, " On Remittent Fever," American Journal Med. Sciences, April, 
1841, New Series, vol. i. p. 289. Elliotson's and Stewardson's Practice of Medi- 
cine, p. 338. 

2 Communicated hy Dr. Stewardson, Am. Journ. Med. Sciences, 1845. 

3 Swett " On Patliol. of Remittent Fever," Am. Journ. Med. Sciences, 1845. 
^ Published by Dr. Alfred Stille, Am. Journ. Med, Sciences, April, 1846. 

5 " An Essay upon the Relation of Bilious and Yellow Fever, prepared at the re- 
quest of, and read before the Medical Society of Greorgia, April, 1856," by Richard 
D. Arnold, M. D. Southern Medical and Surgical Journal, vol. xii. p. 515. 



MALAEIAL FEVER. 



245 



lu all the different forms of malarial fever, intermittent, re- 
mittent, and congestive, which had continued longer than five days, 
and in which there had been no previous structural alterations of 
the liver, as cirrhosis or fatty degeneration, I found the exterior to 
be of a slate color, and the interior of a bronze color. In a case 
of remittent and typhoid fever, the liver presented the true mala- 
rial slate color upon the exterior, and the bronze color in the in- 
terior. 

In cases of death from other causes, during convalescence from 
malarial fever, the color of the liver, both upon the exterior and 
within was not so deep, and presented various shades, from the 
slate, to dark Spanish brown. The change in the color appears to 
be very persistent. I have, in several cases, observed that the 
liver retained shades of light slate and light bronze, several weeks 
after the relief of the attack of malarial fever. 

The liver of a stout American seaman, who had died from a 
severe attack of congestive fever, of only three and a half days' 
duration, presented upon the exterior, a color only a shade darker 
than usual, with the exception of two slate-colored spots. The 
largest of these slate-colored spots, was four inches in diameter, 
and was situated upon the anterior surface of the right lobe, whilst 
the smallest was situated upon the posterior surface, of the left 
lobe. When an incision was made into the structures of the liver, 
through these spots, the substance presented a bronze color for the 
depth of a quarter of an inch. In all other parts of the liver, the cut 
surface presented a color only a shade deeper than normal. 

In a case of congestive fever of the most sudden onset and rapid 
progress, which was ushered in by vomiting, complete exhaus- 
tion of the muscular and nervous forces, and profound coma; a 
large portion of the surface of the liver presented the healthy Span- 
ish-brown color, and when cut, the substance presented the usual 
healthy color, whilst the other portions presented a mottled appear- 
ance of Spanish-brown and dark purple, and the bloodvessels of 
these parts appeared to be engorged with blood. The right lobe 
of the liver had upon its under surface a spot about two inches in 
diameter, of a dark slate (malarial color). When an incision was 
made through this portion of the liver, it presented for the depth 
of about one-fourth of an inch, the true bronze color. 

Numerous incisions were made into the liver in all directions, so 
as to expose its substance fully to view ; portions were found, ap- 
proaching in color the bronze hue of the malarial fever liver ; the 



246 



OBSEEVATIONS OIT 



great mass of the liver, however, resembled more nearly that of a 
healthy liver engorged with blood. Portions from different parts 
of the liver were examined under the microscope. 

The liver cells, from the slate-colored and bronzed portions, did 
not differ in appearance under the microscope, from those of the 
normal colored, or from those of the mottled portions. 

The colored corpuscles appeared to be more altered in form in 
the bronzed portions, than in the normal colored portions. The 
alterations, however, even in the bronzed portions, were small and 
by no means universal, but confined to a few, and after all, the differ- 
ence may have been imaginary. The determination of comparative 
alterations of this kind is not so easy as at first sight appears. 

Did not discover any of those dark granules in the bronze por- 
tion, which have been said to impart the peculiar color to the ma- 
larial liver. The liver cells did not appear under the microscope 
to have been altered in any manner. 

Effects of Previous Pathological Alterations upon the Color 
OF THE Liver, in Malarial Fever. 

Ill maldng examinations of tlie differe.nt organs after deaths and in 
attempting to determine definitely the changes of color ^ ice should always 
determine^ if ]Jossille^ the condition of the liver previous to the disease. 

There are two affections of the liver which are attended with 
profound alterations of the structures, and always modify the color 
characteristic of malarial fever. 

The liver of an Irishman, who died in the latter stages of phthisis 
pulmonalis, from intermittent fever, presented a purplish-red color, 
notwithstanding the presence of the disease long enough to have 
produced the decided slate and bronzed color. The structure was 
unusually firm; it required considerable force to tear it asunder. It 
cut toughly under the knife, and the lobules started out from the 
cut surface, as if they had been bound down. The fibrous capsule 
surrounding the exterior of the liver, forming a sheath for the 
larger vessels lying in the portal canals, was thickened. The in- 
dividual lobules of the liver were surrounded with fibrous tissue. 
Here then we have the explanation of the variation of the color of 
the liver from that characteristic of malarial fever. 

The lobules of the liver have been described by Malpighi, ^ 



1 Malpiglii, De Viscerum, Structura Bologna. London, 1699. 



MALAKIAL FEVER. 247 

Kiernan/ Miiller,^ Leidy,^ and others, as isolated from each other, 
and each invested with a layer of areolar or fibrous tissue. In the 
pig, in which these lobules were first noticed, and in the Polar bear 
according to Miiller, and in the Octodon Cummingii, according to 
Hyrtl," the lobules are invested by fibrous tissue, but in the liver 
of the human subject, and in that of vertebrate animals generally, 
the lobules are not separated from each other by a fibrous parti- 
tion, and there is no areolar or fibrous tissue or prolongation of 
Glisson's capsule between them or in their interior. 

Yogel, Henle,^ Bowman,^ and Beale,^ have failed to detect any 
fibrous tissue in the interlobular fissures of the normal human liver. 

In cirrhosis of the liver, on the other hand, there is a remarkable 
development of fibrous tissue in the parenchyma of the liver ; and 
the individual secreting segments become prominent or even firm 
isolated lobules. 

The increase of fibrous tissue in the liver of this subject was 
manifest to the eye, and especially when the liver was subjected to 
the action of a stream of water, and gently mashed between the 
fingers. The softer parts were washed out and the fibrous tissue 
remained. The character of this was determined by microscopical 
examination. The portions of the liver surrounded by the indu- 
rated fibrous tissue appeared to be but little altered, and could be 
readily scraped away. 

The cirrhosed condition of the liver was not the result of mala- 
rial fever, for the microscopical examination showed that the fibrous 
tissue was abundant and well formed. The whole structure of the 
liver could not have been pervaded with fibrous tissue in a few 
days. It is reasonable to conclude with Dr. Budd,^ that the re- 

' "The Anatomy and Physiology of the Liver," by Francis Kiernan, Philoso- 
phical Transactions of the Royal Society of London, 1833, p. 714. 

2 Miiller, De Glandularum Secernent Struct. Penit, Berlin, 1830. Elements of 
Physiology, by J. Miiller, M. J)., translated by Wm. Baly, M. D. London, 1840 ; 
vol. i. p. 493. 

3 "Researches into the Comparative Structure of the Liver," by Joseph Leidy, 
M. D. American Journal of the Medical Sciences, New Series, vol. xv., 1848, p. 18. 

4 Hyrtl, Lehrbuch der Anatomie des Menchen., 1850. 

5 Hufeland's Journal, 1838, p. 8. 

6 Article " Mucous Membrane " in Todd's Cyclopaedia of Anatomy and Physiology, 
by W. Bowman, vol. iii. p. 497. The Physiological Anatomy and Physiology of 
Man, by Todd and Bowman. Philadelphia, 1857, p. 773. 

' On Some Points in the Anatomy of the Liver of Man and Vertebrated Ani- 
mals, by Lionel S. Beale, M. D. London, 1856, pp. 13, 16, 19, 72. 

^ On Diseases of the Liver, by George Budd, M. D. London, 1857, p. 143. 



2-18 



OBSEKVATIONS ON 



markable changes in cirrhosis, are mainly the consequences of ad- 
hesive inflammation in the areolar tissue about the small twigs of 
the portal vein, and in the areolar tissue of the portal canals, by 
which serous fluid and coagulable lymph are poured out. In this 
stage the liver may be enlarged. The serous part of the effusion 
is next absorbed, the lymph contracts, becomes converted into 
dense fibrous tissue, which divides the lobular substance of the 
liver into well defined masses, and gives great density and tough- 
ness to the organ. Finally, this fibrous tissue compresses the 
small twigs of the portal vein and the small gall-ducts, and thus 
impeding the escape of the bile and the flow of blood induces great 
atrophy of the original hepatic tissue, and causes by a deprivation 
of blood and the admixture of this dirty white fibrous tissue, 
marked changes in the color of the liver. If these views of Dr. 
Budd be correct, it is evident that this condition of the liver could 
not have resulted from an attack of malarial fever, which had com- 
menced only twelve days before death. 

This patient was an Irish laborer. This class are addicted to the 
free use of ardent spirits, and the true cause of this cirrhosed con- 
dition of the liver was the action of the alcohol in the portal 
blood, absorbed directly from the stomach and intestines upon the 
bloodvessels and secreting apparatus of the liver. We know that 
this form of disease is most frequent in large manufacturing towns, 
among the poorer classes, who drink large quantities of ardent 
spirits. All the cirrhosed livers which I have had an opportunity 
of examining, have been taken from the bodies of those who have 
been accustomed to the free use of spirits. So common and well 
known is this cause, that cirrhosis is familiarly termed by the 
English practitioners, gin-drinker's liver. 

The color of the liver of this patient was very different from that 
generally presented in cirrhosis. Upon the inferior surface of the 
liver, there was a small portion of a dark slate, inclining to bronze 
color, resembling the color of the malarial fever liver, and forming 
a striking contrast with the surrounding purplish red color. 

In cirrhosis, owing to the admixture of fibrous tissue and the 
impediment to the circulation of the blood, and the passage of the 
bile, and the compression of the capillaries and secreting apparatus, 
the normal dull-reddish brown color of the liver is altered some- 
times to a bright canary yellow, sometimes to a brownish or 
greenish, and occasionally to a reddish color. A section of the 



MALARIAL FEVER. 



249 



liver upon a general view presents the grayish and yellow color of 
impure beeswax. 

In this case, owing to the pathological conditions of cirrhosis, 
the admixture of fibrous tissue, impediment of the circulation of the 
blood, and flow of bile, and the compression of the capillaries and 
secretory apparatus, the color of the liver was not so marked as in 
those cases of malarial fever in v/hich the liver was normal before 
the introduction of the malarial poison. 

Allowing due weight to the pathological changes of cirrhosis, it 
is evident that the change in the color of the liver was similar, in 
all respects, to the slate and bronze color of livers which were nor- 
mal before the onset of the malarial fever. 

The liver of a house painter, luho died suddenly during convaJes- 
eencefrom a severe attach of malarial fever ^ presented upon a general 
view, a light slate color, with purplish and brownish reflections. 
Upon nearer inspection, it presented a mottled appearance, many 
of the lobules presented the yellow color of cirrhosis. The cut 
surface presented upon a general view a light bronze and pur- 
plish yellow color. Upon close inspection, the yellow lobules were 
distinctly visible. Structure of the liver unusually firm, it re- 
quired great force to tear it. The yellow color of many of the 
lobules and the large admixture of dense fibrous tissue prove that 
this liver was in a cirrhosed condition previous to the attack of 
malarial fever. The yellow color of the cirrhosis was masked very 
much by the characteristic effects of the malarial poison. 

In the case of a German barkeeper, who died -with congestive fever 
after seven days'' sickness, the liver presented a singular mottled 
appearance; at a distance, it presented a light bronzed color; upon 
nearer inspection the lobules were found to be distinct, elevated, 
and of a light bronze color, whilst the spaces between the lobules 
inclined to a slate color. There were several spots, varying from 
two inches to half an inch in diameter, of a uniform slate color. 
The structure of the liver was unusually firm, it required consider- 
able force to tear it asunder, it cut toughly under the knife, and 
the lobules started out from the cut surface as if they had been 
bound down. The fibrous capsule surrounding the exterior of the 
liver, and forming a thick sheath for the large vessels lying in the 
portal canals, was thickened, and the individual lobules of the- liver 
were surrounded with fibrous tissue. 

These facts, which were demonstrated, not only by the touch 
and naked eye, but also by the microscope, showed that this liver 
17 



250 



OBSERVATIONS ON 



was in a cirrhosed condition. Cirrhosis of the liver in this case 
was not caused by the action of the malarial poison, but in all pro- 
bability by the habitual use of ardent spirits. This patient was a 
barkeeper. Men in this occupation are, as a general rule, addicted 
to the free use of ardent spirits. The liquors drank in this country, 
at the hotels and bar-rooms, contain much alcohol, which acts upon 
the secreting structures of the liver, and upon the bloodvessels, and 
excites adhesive inflammation in the areolar tissue, about the small 
twigs of the portal vein, and in the areolar tissue of the portal 
canals, by which serous fluid and coagulable lymph are thrown out. 

Under the microscope, the substance of the liver contained many 
dark-looking masses resembling the altered blood-corpuscles of the 
spleen, and the black granules and flakes of black vomit. These 
dark masses were not sufficiently numerous to produce any marked 
effect upon the color of the organ. When the fibrous capsule was 
torn oft* it presented a light slate color, and yet, when magnified 
and carefully examined, but few of these dark masses were seen in 
the meshes. 

The structures of the liver and the liver-cells contained numerous 
oil-globules. These oil-globules existed in sufficient numbers to 
induce the belief that the liver was in a state not only of cirrhosis, 
but also of fatty degeneration. 

The mottled appearance of the liver, and the want of that decided 
slate and bronze color characteristic of malarial fever, were due not 
to any peculiar effects of the malarial poison, but rather to the 
pathological conditions of cirrhosis and fatty degeneration. Allow- 
ing due weight to these pathological changes, it is evident that the 
change in the color of the liver was similar in all respects to the 
slate or bronze color of livers which were normal before the onset 
of the malarial fever. 

These fiicts show the importance, in all pathological investiga- 
tions of the physical and chemical changes of the organs after 
death, of determining definitely the previous diseases and habits of 
the patients. Without such examinations the most erroneous con- 
clusions might be drawn with reference to the nature of the struc- 
tural alterations of the different organs, especially of the liver, 
during disease. 

The length of the disease should always be accurately ascer- 
tained. We know that the malarial poison is in many cases either 
from peculiarities of constitution, or changes in the forces induced 
by bad habits and previous diseases ; or from the amount and con- 



MALAEIAL FEVER. 



251 



centration of the dose; or from the extent and importance of the 
offices of the organ upon which its force appears to be mainly 
expended; exceedingly rapid and violent in its action — death in 
some cases occurring in 40 hours after the appearance of the first 
symptoms. If the patients thus suddenly attacked have never 
been exposed previously to the malarial poison, we should not 
expect to find the characteristic alterations in the color and struc- 
tures of the liver and spleen as well m^arked as in cases of longer 
standing, for all morbific changes attended with physical changes 
of structure and color are attended by definite chemical changes, 
and in most cases are absolutely dependent upon such changes, 
either in the blood or in the nervous systems or in the structures 
of the organs ; and as every chemical change requires time for its 
production and completion, so must every pathological change have 
time for its production and completion. The pathological altera- 
tions of the organs would be most decidedly manifested, even after 
apparent sudden attacks in those who have resided for some time 
previous in the malarious district, for in two instances on record, 
the bronzed liver was found a year and more after the patient had 
suffered from remittent fever, and, in the interval these persons had 
enjoyed good health. 

In localities like Savannah, Charleston, ISTew Orleans, and Mobile, 
where the yellow fever has prevailed as an epidemic, it w^ould be 
exceedingly important and interesting to determine the effects of 
previous attacks of yellow fever upon the structures and color of 
the liver, and the characters of the alterations presented in a sub- 
sequent attack of malarial fever. Judging by the extent and 
character of the alterations of the liver in yellow fever, we would 
say that they were as persistent as those of malarial fever, and that 
they would, like the alterations of cirrhosis and fatty degeneration, 
mask the characteristic color of the malarial liver. These facts 
demonstrate the extent and complexity of pathological phenomena 
and the number of the sources of uncertainty and error in patho- 
logical investigations. 

Changes op the Color of the Blood in the Liver of Malarial Fever. 

The blood of the liver in malarial fever presents a dark brovvnish- 
red and dark purplish-red color, often inclining to black, and does 
not change to the arterial hue when exposed to the atmosphere. 
If the patient dies within two days of the commencement of the 
disease, there may be a change in portions of the blood issuing 



252 



OBSEEYATIONS ON 



from the cut surface, to the arterial hue. This change takes place 
also in the blood of the livers, taken from patients who have died 
from other diseases, during convalescence from malarial fever. 

Sources of the Change of Color in the Liver during Malarial 

Fever. 

The change in the color of the liver during malarial fever is due to 
changes in the amount^ and physical and chemical constitution of the 
hlood in the capillaries of the liver^ and to the physical and chemical 
changes in the hile^ and the contents of the secretory apparatus. 

Dr. A. Clarke^ has announced that the hue peculiar to the malarial 
liver " is produced by an infinite number of colored microscopical 
particles of irregular shape and size, totally different from anything 
that enters into the constitution of the healthy liver; that these 
colored particles are scattered irregularly through the hepatic tis- 
sue, are seen to occupy the secreting cells of the organ, and even 
the nuclei of these cells ; that they vary in hue from red or orange 
to an opaque, jet black, though much the greater number are of 
a semi-transparent dark-brown color ; and that, in shape, the red 
and dark-brown particles are, some beautifully crystallized, some 
in globular dots and grains; while the black, often in globular 
grains, are also seen in friable, serai-crystalline scales, some of them 
almost large enough to be seen by the naked eye. The nature of 
this coloring matter must be sought among the chemical transfor- 
mations of hematin, or coloring principle of the blood. The belief 
is expressed that in the remittent fever, as in many other diseased 
states, the hematin is readily yielded by the blood, and, passing into 
the liver substance, there meets with some unknown agent, which 
changes its chemical constitution, and converts it into the forms 
and colors here described." 

AVith reference to the extent and character of his investigations, 
Dr. Clarke states in a note appended to the first volume of Dr. La 
Eoche's learned work on yellow fever: " The hospital with which I 
am connected, though a very large one, does not receive many cases 
of this disease, and within the paved and sewered districts of this 
island it is virtually extinct. In the last seven years, I may have 
witnessed seven post-mortem examinations, and though I have not 

' The History, Diagnosis and Treatment of the Fevers of the United States, hy 
Elisha Bartlett, M. D. Edited by A. Clarke, M. D. Philada. 1856, pp. 370, 371. Yel- 
low Fever considered in its Historical, Pathological, Etiological and Therapeutical 
Relations, by R. La Roche, M. D. Philadelphia, 1855, vol i. pp. 610-615. 



MALAEIAL FEVER. 



253 



kept notes of them, I can trust my recollection to assert that I 
have seen no instance in which one of the recognized hues did not 
exist. 

"Portions of the liver in each one of these cases have been studied 
with the aid of the microscope, and in all, the coloring matter here 
called hematoidin has been found abundant, and in each case, as 
far as could be judged, the quantity was nicely proportioned to the 
intensity of the abnormal color." — p. 614. 

The careful microscopical examination of the livers of fifteen 
cases of intermittent, remittent and congestive fever, has convinced 
me that whilst the red and dark-brown and black granules do 
occur in some cases of malarial fever, they are absent in the livers 
of others which do not differ in color from those in which they are 
present. I have seen the slate and bronze color of the liver as well 
marked in the liver when these dark masses were absent, as in the 
liver when they were most abundant. Careful microscopic exami- 
nations of the slate and bronze colored spots in the livers of those who 
had died suddenly with malarial fever, and of the slate and bronzed 
colored spots sometimes found upon the kidneys in malarial fever, 
demonstrated that this hue was just as decidedly marked when 
there was an entire absence of the peculiar dark masses. 

That the peculiar color of the liver is due in a great measure to 
changes in the coloring matter (hasmatin) of the blood, is indicated 
by the fact that the blood from the capillaries of the liver will not 
change from the dark reddish-brown and purplish color to the 
arterial hue. It is probable that the altered coloring matter, result- 
ing from the destroyed disintegrated blood-corpuscles, or from the 
blood-corpuscles acted on by the malarial poison without actual 
disintegration, escapes and permeates the surrounding tissues, and 
imparts the peculiar color of the liver. 

The color of the liver remains the same, whether the coloring 
matter be retained in solution, or is precipitated, forming the dark 
granules. 

The peculiar hue appears to be also due to the altered color 
of the bile. In all the cases of malarial fever which I have thus 
far examined, I have found the bile to be of high specific gravity, 
thick, concentrated, and of a greenish-black color when seen in 
mass, and of a gamboge yellow when spread in thin layers. The 
liver cells under the microscope presented a light greenish-yellow 
color, as if they also were infiltrated with the altered coloring matters. 
In some cases the liver-cells contained fewer oil-globules, and the 



251 



OBSEEYATIONS ON 



cell-T^•alls looked thinner than usual ; in other cases they resembled 
closely the healthy cells. 

The peculiar color of the malarial liver can, to a certain extent, 
be extracted by boiling water. 

In almost every case I found the filtered decoction of malarial 
fever livers, to be of a brownish-yellow color, whilst the decoction 
of yellow fever livers is of a bright golden color, whilst that of 
normal livers is of a light yellow. These observations, however, 
should be repeated upon an extensive scale, before we can decide 
upon the characteristic color of the decoctions of the liver in dif- 
ferent diseases. 

After the altered coloring matters of the blood and bile have in- 
filtrated the structures of the liver, they will sometimes remain for 
a considerable length of time without being absorbed, and it may 
communicate the peculiar bronzed color to the liver, long after the 
restoration of its normal functions, and the disappearance of the 
malarial fever. I have observed, however, that the intensity of the 
color of the liver bears a marked relation to the time of convales- 
cence ; as convalescence advances, the color diminishes. 

Characters of the Bile in Malarial Fever. 

The gall-bladder, in fifteen cases of the difierent forms of mala- 
rial fever, was filled with bile, which had, in the majority of cases, 
the consistency of molasses, and presented a greenish-black, with 
yellowish and reddish reflections when seen in mass, and of a gam- 
boge-yellow when spread in thin layers. In every case the mucous 
membrane of the small intestines were colored yellow by the bile 
throughout almost the entire extent, and in many cases the mucous 
membrane of the stomach was in like manner discolored with bile. 
The characters of the bile vomited during life, corresponded to that 
found in the gall-bladder after death. 

In a case of congestive fever of only forty -three hours' duration^ the 
specific gravity of the bile was 1042.5, and viewed in mass it pre- 
sented a brownish-black color with greenish reflections, and re- 
sembled, upon a general view, a saturated tincture of iodine. It 
poured like molasses, being thick and ropy. Upon close inspec- 
tion, the bile was found to contain numerous flakes of a green color, 
which, under the microscope, were found to consist of the con- 
glomerated cells of the mucous membrane of the gall-bladder. 



MALARIAL FEVER. 



255 



When spread out in thin layers, the bile presented a gamboge-yel- 
low color. 

In a case of malarial fever of eleven weeks, which had been en- 
tirely without treatment during the first eight weeks, and which 
ended in extensive disorganization of the blood, muscular system, 
and spleen, the gall-bladder was filled with bile of a brownish- 
5^ellow opaque color, when seen in mass, and of a gamboge-yellow 
in thin layers. The bile contained numerous, irregularly-shaped, 
yellow masses of various sizes, from an English pea to a grain of 
sand. These yellow masses formed about two-fifths of the contents 
of the gall-bladder. These masses were soft, and readily crushed 
between the fingers. Under the microscope, they were found to 
consist of numerous cells from the mucous membrane of the gall- 
bladder, and a yellow amorphous matter. The bile-duct appeared 
to be completely stopped up with these cells, and this yellow amor- 
phous matter. The specific gravity of this specimen of bile was 1036. 

In the case of the house painter who died suddenly during con- 
valescence from a severe attack of remittent fever, the bile pre- 
sented a brownish-yellow color in mass, and a gamboge-j^ellow 
color in thin layers. It was tenacious like mucus; in fact, it re- 
sembled closely colored mucus, specific gravity 1022.5. 

The liver of those cases which died in the active stages 
of malarial fever contained animal starch (glucogenic 
MATTER, Bernard); whilst hepatic sugar was entirely absent. 

The liver of every fatal case of malarial fever was carefully tested 
for animal starch and grape sugar, and the results never varied ; in 
iatermittent, remittent, and congestive fevers, animal starch (glu- 
cogene) was always present, while grape sugar was always absent. 

In many cases when the fibrous capsules of the livers were torn 
off, partially dried, and treated with tincture of iodine, the cellular 
tissue was not altered by the tincture of iodine, but whenever a 
particle of liver adhered to the fibrous tissue, these purple and blue 
masses could be detected with the microscope. In cirrhosed livers 
the fibrous tissue of the liver generally, and of the portal canals, 
were found to be completely infiltrated with this animal starch. 
When single cells of the malarial liver were treated with tincture 
of iodine, I was not able to demonstrate satisfactorily, whether they 
contained animal starch. When, however, a number of them in 
mass were treated with tincture of iodine, the characteristic blue 
color was produced. 



256 



OBSERVATIONS ON 



In several cases the hepatic ducts were isolated and treated with 
tincture of iodine, and carefully examined under the microscope ; 
in some cases the ducts were dotted with blue particles, whilst the 
other portions were simply changed to the color of the iodine, 
and in other cases long portions of the hepatic ducts were changed 
to a bright blue color. These facts show that the hepatic ducts 
sometimes contain animal starch. 

From chemical examinations of the livers of the different forms 
of malarial fever, from the summer of 1856 to the present time, I 
have obtained similar results. In many cases the livers were set 
aside, and examined after intervals of twelve hours; the last exa- 
minations were made thirty-six hours after the first ; and at every 
examination the result was the same — the presence of animal starch, 
"without a trace of grape sugar. 

The mere presence of starch in the liver is not peculiar to mala- 
rial fever ; it is not a pathological condition. 

In the month of September, 1856, I had an opportunity of exa- 
mining chemically the liver of a patient, who had been under the 
care of my friend and former colleague, Dr. J. B. Read. This pa- 
tient had black vomit, and all the symptoms of yellow fever, and 
the liver presented the yellow boxwood color peculiar to this dis- 
ease. Chemical examination gave decided evidence of the presence 
of animal starch in the structure of the liver. The liver of a yellow 
fever patient brought from Norfolk by Dr. J. B. Read presented 
a similar appearance, and also yielded animal starch. I have de- 
tected this substance in the human liver, in normal condition after 
sudden death from diseases of the circulatory apparatus, and apo- 
plexy, and phthisis, and in abnormal states, as cirrhosis, fatty de- 
generation, and cirrhosis and fatty degeneration combined. 

1 have examined the livers of numerous vertebrate animals, in- 
jected and uninjected, and in every instance animal starch has been 
found. 

Whether the elaboration of this product is confined specially to 
any one of the anatomical elements of the liver, I have not as yet 
been able to determine with certainty, for it has been found in the 
fibrous tissue of the portal canals, in the hepatic ducts, and in seve- 
ral cases, in the lower animals, in the secreting cells. We would 
naturally infer that it was formed in and by the secreting cells of 
the liver, and was deposited in other positions by endosraosis. The 
exact point at which it is converted into grape sugar is unknown. 
Bernard has shown that this change is due to the action of a special 



MALAKIAL FEVER. 



257 



ferment contained in the blood. Experiments have shown that the 
liver-cells contain grape sugar as well as the hepatic veins. If the 
starch is formed in the secreting cells, and grape sugar is formed 
in them also, then the special ferment of the blood must be absorbed 
by the secreting cells. A portion of the animal starch may be ab- 
sorbed by the hepatic veins, and be acted upon by the ferment only 
partially if in large quantities, and finally be deposited in the organs 
and tissues. 

This view is partially sustained by the fact that this substance is 
not confined to the liver; for I have found it in considerable abund- 
ance in malarial fever spleens, and in normal spleens taken from 
patients who had died from cirrhosis and fatty degeneration of the 
liver combined, and in one case where the patient (an aged negro 
man) had died suddenly from apoplexy. A carbo-hydrate, similar 
in its composition and properties to vegetable cellulose, has been 
found in some of the lower animals. C. Schmidt' discovered cel- 
lulose in the mantle of phallusia mammillaris (one of the mollusca), 
and Lowig^ and Kolliker have discovered it in the outer tube of 
salpse, in the leathery mantle of the cynthiae, and in the cartilagi- 
nous capsule of the simple ascidiiB. The researches of Odier,^ Las- 
saigne,'' Payen,^ Children,^ and Danniel,and especially of C. Schmidt,^ 
have shown that a body closely resembling cellulose (vegetable 
fibre), which C. Schmidt regards as composed of a carbo-hydrate, 
and of a nitrogenous body having the composition of the muscular 
fibre of insects, forms the true skeleton of all insects and Crustacea. 
This substance, called chitin, constitutes not only the external ske- 
leton, the scales, and hairs of insects, but it also forms their trachese, 
and even one of the layers of the intestinal canal. Cellulose, or 
animal starch, has been discovered by Kudolph Virchow,^ in the 
brain, and in some of the higher nerves of sense. These observa- 

1 Zu Vergl. Physiol, der Wirbellosen Tliiere, 1845, S. 62. See also " Contribu- 
tions to the Comparative Physiology of the Invertebrate Animals, being a Physio- 
logico-Chemical Investigation," by Dr. Carl. Schmidt ; Taylor's Scientific Memoirs, 
vol. V. part xviii., 1852, p. 34. 

2 Ann. de Scienc. Nat., 3d series, torn. v. pp. 193-232. 

3 Memoire de la Societe d'Histoire Naturelle, tom. i. p. 29 et seq. 
Comptes Rendus, tom. xvi. p. 1087 ; Journ. de Chim. Med., 1-9, p. 379. 

5 Comptes Rendus, tom. xvii. p. 227. 

^ Todd's Cyclopsedia of Anatomy and Physiology, vol. ii. p. 882. 
' Zur Vergleichend, Physiol, der Wirbellosen, Thiere. 1845, S. 32-69 ; trans, in 
Taylor's Sci. Memoirs, vol. v., 1852, pp. 14-28. 
^ Virchow's Archiv., b. vii., h. i., p. 135. 



258 



OBSEEVATIOXS OX 



tions were subsequently confirmed by those of George Busk. In 
1853, Yirchow' announced the discovery of corpuscles, presenting 
the sanae reaction as the corpora amylacea of the brain, in the Mal- 
phighian corpuscles of diseased human spleens, in the condition 
termed waxy spleen. Yirchow, Bennet, and Carter, have also 
pointed out the existence of a peculiar amyloid substance in the 
liver, in some chronic forms of disease, as waxy or fatty degenera- 
tion. At a meeting of the Academy of Sciences, March 23, 1857, 
M. CI. Bernard announced "that the livers of dogs, fed exclusively 
on meat, possess the property of forming a glucogenic substance, 
analogous to vegetable starch, and alike susceptible of an ultimate 
transformation into sugar, passing through the intermediate condi- 
tion of dextrine." Sanson, Longet, Bouley, Poggiale, Parry, and 
others, have recorded similar facts with reference to the occurrence 
of a substance having very much the same chemical constitution 
and properties of starch in the liver, and the results of the experi- 
ments and researches of Bernard and these observers prove that in 
herbivorous animals this substance may be found in other organs 
besides the liver. 

The presence of animal starch, and the absence of hepatic sugar, 
in malarial fever, would seem to indicate that the special ferment 
in the blood whicli transforms animal starch into glucose, had been 
destroyed, whilst the power to manufacture starch from both nitro- 
genized and non-nitrogenized materials was exercised by the liver, 
and hence the absence of glucose, and the accumulation of gluco- 
gene. 

Some of the Points of Difference between the Malarial Pever 
AND Yellow Fever Liver. 

The liver of yellow fever, as far as my observations extend, and 
according to the observations of Louis and many other observers, 
is of a bright yellow color. It is probable that this color, as in 
the case of that of the malarial liver, varies with the length of the 
attack, and the effects of previous diseases. Thus Dr. Samuel 
Jackson, of Philadelphia, found the livers in cases which had died 
suddenly in the early stages, engorged with dark blood. 

As far as my observation extends, the decoction of the yellow 
fever liver is of a bright golden color, whilst that of the malarial 

' Journal of Microscopical Science, No. vi. p. 101. 



MALAEIAL FEVER. 



259 



fever is of a brovvnisli yellow. The golden color of the yellow 
fever liver can be extracted both by alcohol and water. 

The yellow fever liver is much firmer and harder than that of 
malarial fever, contains much less blood and is much less readily 
acted upon by liquor potass^e and acids. Liquor potassae readily 
dissolves the malarial fever liver, and the decoction presents the 
appearance of venous blood, while no such effect is produced by 
the action of this substance upon the yellow fever liver. 

Spleen. 

The complexity and difficulty of pathological inquiries are 
again illustrated, by the different views which prevail with refe- 
rence to the offices of the spleen. Whilst Grerlach, Yirchow, and 
Bennet, consider the spleen as the birthplace of the colored cor- 
puscles, Kolliker, Ecker, Beclard and Gray, consider it the organ 
in which the blood-corpuscles die and are disintegrated. 

The difficulty of settling this question definitely, is increased by 
the equivocal and uncertain results of comparative anatomical in- 
vestigations, and of physiological experiments. If the function of 
the spleen be that of the formation and destruction of the blood- 
corpuscles, it is reasonable to suppose that it should be much larger 
in warm than in cold-blooded animals, because the number of the 
blood-corpuscles is greater, and all the changes of the elements of 
the fluids and solids much more rapid in the former than in the 
latter. To determine this point, I ascertained accurately the weights 
of the bodies and spleens of cold and warm-blooded animals.^ 

The following table presents a condensed view of the results, the 
accuracy of which I have confirmed again and again, by numerous 
dissections and comparison of the spleen in the different classes of 
animals. 

Comparative Weights of the Spleens of Animals. 

Number of times 
the weight of 



Fishes. its spleen. 

Weight of the body of Trygon sahina (Stingray), female . . 292 

" " Trygon sabina (Stingray), foetus . . 1016 

" " Zygsena malleus (Hammerhead Shark) . 601 

" " Zygaena malleus (Hammerhead Shark) . 443 

" " Lepisosteus osseus (Garfish) . . . 587 

" " Lepisosteus osseus (Garfish) . . . 599 



• "Investigations, Chemical and Physiological, relative to certain American Yer- 
tebrata," by Joseph Jones, M. D., Smithsonian Contributions to knowledge, July, 
1856, pp. 116-122. 



260 



OBSERVATIONS ON 



Comparative Weight of the Spleens of Animals — Continued. 







Is'umber of times 
the weight of 








ts spleea. 






Reptiles. 




Weight of the body of Rana catesbiana (Bullfrog) 


2279 






Heterodon niger (Black Viper) . 


25666 


<( 


({ 


Psammopliis flagelliformis (Coacliwliip 
bnaKe ) . 


6426 




{( 


Coluber guttatus (Corn Suake) . 


9600 


u 




Coluber constrictor (Black Snake) 


7285 


11 




Crotalus adamanteus (Rattlesnake) . 


15450 


11 


li 


Alligator Mississippiensis (Aligator), male 


1319 


11 


11 


Alligator Mississippiensis (Aligator), female 


798 




it 


Chelonia caretta (Loggerhead Turtle) 


2201 


« 




Chelonura serpentina (Snapping Turtle) . 


800 




11 


Emjs terrapin (Salt-water Terrapin) . 


7958 




11 


Emys reticulata (Chicken Terrapin) . 


965 




a 


Emjs serrata (Yellow-bellied Terrapin) 


1618 


« 


(( 


Emjs serrata (Yellow-bellied Terrapin) 


1125 




a 


Testudo polyphemus (Gopher) . 


2575 


(( 


u 


Testudo polyphemus (Gopher) . 


3600 



Birds. 

Weight of the body of Meleagris gallopavo (Wild Turkey), female 1538 
" " Meleagris gallopavo (Wild Turkey), female 2625 
" " Picus erythrocephalus (Red-headed Wood- 
pecker) 2120 

" " Tantalus loculator (Wood Ibis) . . 3579 

" " Tantalus loculator (Wood Ibis) . . 2044 

" " Syrnium nebulosum (Barred Owl) . . 1470 

" " Cathartes atratus (Black Buzzard) . . 1228 



Mammals. 



Weight of the body of Didelphis Virgiuianus (Opossum) 


. 418 


(( 


u 


Common Sheep ..... 


. 590 


(( 


u 


Sciurus Carolinensis (Gray Squirrel) 


. 682 


(( 


u 


Sciurus capistratus (Fox Squirrel 


. 919 


a 


il 


Cervus Virginianus (Foetus of Deer) . 


. 283 


(( 


11 


Cervus Virginianus (Foetus of Deer) . 


. 350 


<( 


11 


Mus rattus (Rat just born) 


. 498 


a 


u 


Mus rattus (Rat just born) 


. 505 


11 


li 


Mus rattus (Rat half grown) 


. 506 


(I 


(I 


Lepus sylvaticus (Common Rabbit) . 


. 1494 


« 


li 


Procyon lotor (Raccoon), female 


. 343 


u 


ii 


Procyon lotor (Raccoon), female 


. 292 


li 


ii 


Procyon lotor (Raccoon), female 


. 391 


a 


11 


Procyon lotor (Raccoon just born) 


. 156 


u 




Pointer Dog, male .... 


. 577 


11 


li 


Common Cat, female .... 


. 522 



MALARIAL FEVER. 



261 



These tables show that the spleen is smallest in birds and ophi- 
dians, and largest in fishes and mammals. 

The temperature of birds is high, their blood-corpuscles numer- 
ous, their life actions vigorous, and the physical and chemical 
changes of the elements of their fluids and solids correspondingly 
rapid. In fishes, circulation and respiration are sluggish, the blood- 
corpuscles few in numbers, the temperature low, the metamorphosis 
of the elements of their structure slow, and the intellect and all the 
life actions correspondingly feeble. If the function of the spleen 
be the construction, destruction, and elaboration of some of the 
important elements of the blood, why is it so small and insignificant 
in birds, and of such great relative magnitude in many cold-blooded 
animals? 

Is it possible that an organ, which, in many ophidians, chelonians, 
and birds, weighs only a few grains, or a small fraction of a grain, 
can exert any important influence upon the physical properties and 
chemical constitution of the blood? Do not these facts show con- 
clusively that we do not understand the functions of the spleen? 

Mr. Gray^ supposes that one office of the Malpighian corpuscles 
is to store up nutritive matter when there is a surplus of alimentary 
materials, to be restored again to the blood when there is a defici- 
ency of these elements. It is, however, difficult to conceive how 
nutritive matter of any importance could be stored up in the Mal- 
pighian corpuscles of organs weighing a few grains, or only frac- 
tions of a grain. The amount accumulated in such organs would 
be microscopic in its character, and not much more than the hun- 
dredth part of a grain. Even in warm-blooded animals, the amount 
of albuminous compounds contained in the Malpighian corpuscles 
of the spleen is insignificant, and unworthy of notice, when com- 
pared with that contained in the circulatory apparatus, the capacious 
reservoir of the nutritive materials. The circulatory apparatus 
of an adult man contains about twenty pounds of blood, whilst the 
Malpighian corpuscles of the spleen are capable of containing only 
a few grains. Would nature construct an organ, an important 
office of which would be to store up a few grains of nutritive 
matter, whilst the circulatory system contains more than ten thou- 
sand times the amount? 

My observations show that the increase of the spleen during 
active nutrition noticed by Mr. Gray in cats, rabbits and rats, is by 



1 The Structure and Use of the Spleen, bj Henry Gray, F. R. S. London, 1854. 



262 



OBSEEVATIONS ON 



no means a universal phenomena in the animal economy. The 
spleens of ophidians and saurians and chelonians did not diminish 
in weight more rapidly than the other organs and tissues, and the 
spleens of salt-water terrapins {emys terrajoin)^ and of yellow-bellied 
terrapins {emys serraia)^ which had been starved and deprived of 
water for a great length of time, and then transferred to a tub of 
water and abundantly supplied with vegetable food, did not exhibit 
any increase in weight. I have also observed, in numerous in- 
stances, that the spleen of cold-blooded animals does not act as a 
diverticulum for any surplus water or nutritive materials in the 
circulatory apparatus. The spleens of many carnivorous chelo- 
nians, whose circulatory apparatus was so filled with blood, conse- 
quent upon a change of diet, that aqueous albumino-saline effusions 
took place into the cellular tissue, and all the cavities presented no 
increase in size or weight. The spleens of ophidians, which are 
voracious and swallow large masses of flesh, were not enlarged, 
notwithstanding the large amount of nutritive substances which 
were received into their circulatory apparatus. 

That the spleen is an organ of subordinate importance in the 
animal economy, will be shown by the following facts: It is ab- 
sent from all invertebrate animals without exception. It is also 
absent from the amphioxus, the connecting link between fishes 
and the hig^her forms of the mollusca. 

The spleen of birds and reptiles is too small to exert an im- 
portant influence in the animal economy. Its size corresponds in 
no manner with the number of colored blood-corpuscles, or the 
rapidity of the composition and decomposition of the organic and 
inorganic elements of the solids and fluids of animals. 

The function of the spleen is not essential to the maintenance 
of life, for it has been excised by numerous observers, without 
the death of the animal, or any manifest alterations in the blood or 
organs, or any diminution of the forces. 

On the other hand, that the spleen has some important ofiice to 
perform in the animal economy, is shown by the fact that in the 
amphioxus and invertebrate animals, which are devoid of spleens, 
the blood-corpuscles are colorless. The occurrence of the spleen is 
accompanied by a change in the color of the blood. The question 
immediately arises, has the spleen anything to do with the produc- 
tion of the red blood-corpuscles of vertebrate animals ? The blood 
of the invertebrata, with its corpuscles, exists before the formation 
of any special organs; and the same fact is noticed in the develop- 



MALAKIAL FEVEE. 



263 



raent of the foetus of warm-blooded animals ; a vascular system 
circulating a fluid containing colored blood-corpuscles exists before 
the formation of any special organs ; and hence it is probable that 
the spleen has little to do with the formation of the corpuscles and 
the production of their red color. This question cannot, however, 
be settled by an appeal to comparative anatomy, or by extirpa- 
tion of the spleen, because it is more than probable that other 
organs possess the power of performing the offices of the spleen 
when it is absent. 

Besides these facts in comparative anatomy, the microscopical 
examinations of the pulp of the spleen by Oesterlen, Eeraak, Hand- 
field Jones, Kolliker, Ecker, Beclard, and Gray, and the com- 
parative analysis of the blood entering in the spleen, and of that 
passing out of these organs, render it highly probable, if not abso- 
lutely certain, that one of the most important of&ces of the spleen 
is the destruction of the colored blood-corpuscles. 

As, therefore, our knowledge of the functions of the spleen is 
not as extensive or as definite as the requirements of exact science 
demand, we should exercise caution in the construction of theories, 
with reference to the efiect of pathological alterations of the spleen 
in diseases. 

Weight of the Spleen in Malarial Fever. 

The following table confirms the statements of numerous observ- 
ers, that the spleen is enlarged in malarial fever. 



Weight of the Spleen in Malarial Fever. 





Avoirdupois 


Avoirdupois 


Troy 




pounds. 


ounces. 


grains. 








f 3062 


WeigM of the spleen in its normal condition 






\ to 






i 2187 


Case of intermittent fever in latter stages of 








plitliisis ..... 




14> 


6343 


" remittent and typhoid fever . 


1 lb. 2 ozs. 


18^ 


7920 


" remittent fever .... 


1 " 15 " 


31 


13562 


" remittent fever .... 


1 " 13 " 


29 


12687 


Two years after attack of remittent fever . 


1 " 14> " 


30.V 


13343 


Case of remittent fever .... 


1 " 2\ " 


181 


8093 


" congestive fever .... 




13.L 


5895 


" congestive fever .... 
" congestive fever .... 


1 " 13 " 


29 


12687 


1 " 1^- " 


17^ 


7562 



This table shows that in seven cases of malarial fever, terminat- 
ing in the active stages, the spleen was enlarged ; the enlargement, 



26i 



OBSEEVATIONS ON 



however, was not so great as in those cases exposed to a longer 
action of the malarial poison. In such cases the spleen is often 
greatly enlarged, and can be often felt during life as a hard mass oc- 
cupying a considerable portion of the abdominal cavity. Cases are 
recorded where the spleen has been said to weigh twenty pounds, 

I have found the spleen of those who died in the active stages of 
malarial fever, not only enlarged, but softened, and filled with dark 
brownish-purple, and brownish-red mud. 

The malarial spleen presents upon the exterior, a dark slate 
color; and the trabeculie and capsule appear to be completely 
altered in structure; so much altered, in many cases, that the 
slightest touch is sufficient to rupture them. I have seen the struc- 
tures of the spleen in malarial fever so much disorganized, that in 
attempting, even in the most careful manner, to remove this organ 
from the abdominal cavity, the trabeculae have given way under 
a slight pressure, and the fingers plunged into its soft substance. 

The dark brownish-purple mud (pulp and extravasated blood) 
of the spleen is composed, in great measure, of colored blood-cor- 
puscles, altered in various degrees, according to the length of the 
attack, and which have lost the power of changing to the arterial 
hue when exposed to the oxygen of the atmosphere. In many 
cases, especially those of long standing, the pulp and extravasated 
blood (mud), of the spleen abounds in dark reddish-brown, and 
reddish-black granules and conglomerated granules, resembling the 
dark particles found in the malarial liver, and in the sediment of 
the black-vomit of yellow fever. Similar bodies, but apparently 
in less abundance, are found in normal spleens. In cases which 
have terminated fatally, after only a short illness of two or three 
days, these bodies resulting from the disintegration of the colored 
blood-corpuscles, were not so numerous as in cases of longer dura- 
tion, and in some very recent cases, they were not more numerous 
than in the spleen of health. AYe will now illustrate the changes 
of the spleen in malarial fever, by cases of varying duration. 

In a case of malarial fever of the congestive type^ of only forty -three 
hours'' duration, the spleen was slate-colored, softened, and enlarged ; 
not as much softened and altered, hov^^ever, as in cases of malarial 
fever of longer standing. The mud of the spleen was of a dark 
purplish hue, and appeared to be in transition to the color and 
state of the mud of the spleens of malarial fever of longer duration. 
After exposure for a few hours to the oxygen of the atmosphere, a 
large portion of the mud of the spleen assumed a color approach- 



MALARIAL FEVER. 



265 



ing the arterial hue; much brighter than the mud of the spleens 
upon which malarial fever had exerted its full effects, and some- 
what darker than the bright arterial hue, assumed by the splenic 
pulp of healthy normal spleens. When the mud was spread in 
thin layers upon a glass slide, the change of color was much more 
rapid. Under the microscope, the splenic mud appeared to consist 
almost entirely of colored corpuscles, many of which appeared 
swollen and altered in appearance. After careful examination, I 
was unable to find those conglomerations of black granules, resem- 
bling the black sediment of black vomit, which were discovered in 
the spleens of malarial fever of longer standing. 

The spleen of a stout Irish seaman^ who died from an attach of 
congestive fever^ fifty hours after the first appearance of disease^ was 
enlarged, softened, disorganized, and of a dark slate-color ; and 
when pressed gently between the fingers, the trabecule© could be 
felt giving way. The cut surface presented a dark, purplish- brown 
color; from the cut surface issued a dark, purplish-brown mud. 
After eight hours' exposure to the atmosphere small streaks, in- 
clining to an arterial hue, appeared upon the cut surface of the 
spleen, and probably were due to the change in the blood which 
issued from the divided vessels. These streaks of splenic mud, in- 
clining to the arterial hue, occupied but an inappreciable fraction 
of the whole surface. When the dark mud (effused blood) was 
examined under the microscope, it was found to consist chiefly of 
colored and colorless corpuscles, and the cells peculiar to the spleen. 
Some of the colored corpuscles were swollen and altered in shape ; 
the alteration was by no means universal or remarkably great. This 
spleen contained, as usual in malarial fever, animal starch. 

The spleen of an American seaman^ ivho died of congestive fever 
seventy hours after the first appearance of disease^ was enlarged, soft- 
ened, and of the dark slate-color usual in malarial fever. When 
the mud of the spleen was exposed to the atmosphere, a part re- 
tained the dark-purplish and reddish-brown color ; whilst another 
smaller portion changed to an arterial hue. The difference between 
these two portions of the splenic mud were clearly seen when a 
section of the organ was exposed for several hours to the action of 
the atmosphere. The other portion of the mud of the spleen did 
not change its color. This phenomenon was, without doubt, due to 
the fact that the blood had been but recently effused into the spleen. 
The portions first effused had lost the power of changing to the arte- 
rial hue ; whilst those last effused had not entirely lost this power. 
18 



266 



OBSEEVATIONS OK 



The spleen of an Irish laborer^ who died suddenly in a congestive 
chilly which had heen 'preceded for three or four days hy an apparently 
mild attach of intermittent fever ^ was slate- colored, enlarged, softened, 
and disorganized, and could not be removed from the abdom.inal 
cavity without rupture of its capsule and trabeculae. The capsule 
and trabeculas appeared to be so altered in structure that the 
slightest touch was sufficient to rupture them. After careful wash- 
ing under a stream of cold water the trabeculas, as usual in mala- 
rial fever, presented a red color. The mud of the spleen was of 
a dark-reddish and purplish-brown color, and consisted princi- 
pally of colored blood -corpuscles, which did not change to the 
arterial hue during fifty hours' exposure to the oxygen of the atmo- 
sphere. The mud and fibrous tissue of the trabeculae and blood- 
vessels of this spleen contained animal starch. 

The spleen of a large^ stout German laborer^ who died of congestive 
fever ^ supervening upon an attach of malarial fever of four days'' 
continuance^ was enlarged and disorganized, and presented a dark 
slate-color. To the touch the spleen felt like a sack filled with 
a viscid fluid. The capsule was torn upon the slightest exertion 
of force. Whilst gently lifting the spleen, to sever its attachments 
and lift it out of the abdominal cavity, the capsule was torn off for 
the space of several inches, and my fingers, which grasped the organ, 
plunged through the disorganized trabeculae and pulp. When the 
spleen was laid upon the table and pressed, the mud within was 
forced into other portions, and the indentation remained, thus show- 
ing that the cells of the spleen communicated freely with each other. 
The spleen was filled with a substance resembling purplish-black 
mud. This splenic mud was very thick, and dried rapidly when 
spread upon glass slides. Under the microscope, this was found to 
consist principally of colored blood-corpuscles. Many of the colored 
blood- corpuscles presented an altered appearance. In some cases 
the color appeared darker than normal. Many of the corpuscles 
were swollen ; whilst others were corrugated. That the colored 
corpuscles had undergone some change was conclusively demon- 
strated by the fact, that the color of this splenic mud did not alter 
during thirty-six hours' exposure to the oxygen of the atmosphere. 
The splenic mud also contained numerous dark granules and gra- 
nular masses. The number of colorless corpuscles were apparently 
diminished. This diminution was in all probability relative and 
not absolute; they appeared to be diminished relatively to the 
immense number of colored blood-corpuscles. 



MALARIAL FEVER. 



267 



The spleen of an Irish seaman., who died ten days after the onset 
of remittent and congestive fever., was of a dark slate-color, and en- 
larged, softened, and the capsule and trabecule© gave way when 
pressed gently between the fingers. When first removed, the mud 
of the spleen coagulated very slightly; the coagulum possessed no 
consistency and no permanence. When the pulp and extravasated 
blood of the spleen were examined under the microscope, it was 
found to consist of colored and colorless blood-corpuscles, and nu- 
merous dark, black granules. These granules were frequently 
conglomerated together, forming dark flakes, like the coffee-ground 
sediment of the black vomit of yellow fever. Many of the colored 
corpuscles appeared swollen. 

The spleen of an Irish laborer., ivho died two weeks after an attach of 
intermittent fever from congestion of the hrain^ was enlarged, softened, 
and of a light slate-color. The pulp of the spleen was of a pur- 
plish and reddish-brown color, and changed to the arterial hue 
upon exposure to the atmosphere. 

The spleen of an Irish haker^ who died during convalescence from 
remittent fever during an attack of pleuro- pneumonia., was slate-colored, 
enlarged, and softened. The pulp of the spleen was firmer than 
that of recent cases of malarial fever, and although it changed to 
the arterial hue more slowly than the pulp of healthy spleens, the 
change of color was much greater than that of the pulp of the 
spleen in the active stages of malarial fever. 

The spleen of a house painter luho had died in convulsions^ three 
iveeks after an attack of remittent fever., was enlarged and softer than 
normal, but much harder than usual in the active stages of mala- 
rial fever. The cut surface presented a compact, dark brown 
almost black appearance. Numerous small white bodies, about 
the size of millet-seed, were found scattered through the pulp of the 
spleen. I had never before seen the splenic corpuscles so numerous, 
large, and distinct. The exterior of the spleen was of a slate color. 
The compact nature of the pulp of this organ shows that it was 
recovering from the effects of malarial fever. 

The spleen of the German hutcher^ who suffered with intermittent 
fever two months., without medical treatment^ and whose disease at the 
end of this time assumed the congestive type^ and although relieved of 
the immediate effects of the malarial poison, fell a victim, after 
three weeks of the most intense and loathsome suffering, to the 
complete disorganization of the solids and fluids resulting from 
the pathological alterations induced by the malarial poison during 



268 



OBSEEYATIONS ON 



the period when it pursued its course unchecked ; presented pro- 
found alterations. This organ was enlarged ; surface covered with 
effused coagulable Ijnnph, and bound to the liver and diaphragm 
by bands of coagulable lymph. A large quantity of pus, of a 
greenish-yellow color, issued from the anterior border of the spleen, 
which was firmly attached to the liver. Whether the abscess had 
opened and discharged the pus before death, or whether the abscess 
was accidentally ruptured during the opening of the chest and 
abdomen, I was unable to determine. 

The structure of the spleen felt firm, very unlike the soft yielding 
structure of the spleen of the active stages of malarial fever. AVhen 
cut, many portions of the spleen resembled a dark bronzed and 
slate colored liver. The pulp of these portions was not soft, and 
did not pour out like the pulp of the spleen of the active stages of 
malarial fever. 

The liver-like substance of the spleen was found to consist under 
the microscope of fibrous tissue, and numerous colored corpuscles 
and flakes, composed of granules resembling the dark colored 
flakes of the black vomit of yellow fever. These flakes were with- 
out doubt derived from the coloring matter of the colored blood- 
corpuscles. The colorless corpuscles of this portion of the spleen 
appeared to be more numerous than usual. This dark liver-like 
substance appeared to be nothing more than the extra vasated blood 
and the pulp of the spleen, effused and altered during the active 
stages of the fever, from which the serum has in a great measure 
been removed, and in which alterations of the colored corpuscles 
have taken place, and fibrous tissue formed. After several hours' 
exposure to the oxygen of the atmosphere, the color of this portion 
of the spleen was not altered. In addition to the abscess opening 
upon the surface of the spleen attached to the liver, the substance 
of the spleen contained numerous smaller abscesses of various 
sizes (two or three of the largest were of the size of a bullet, and 
the smallest of the size of an English pea), filled with thick greenish- 
yellow pus. Portions of the spleen, especially surrounding the 
abscesses, were altered into a cheese-like substance. Under the 
microscope, these cheese-like portions consisted almost entirely of 
pus-corpuscles, and large cells containing granules and other 
smaller cells ; and also black masses composed of granules, and also 
numerous oil-globules. The large mother cells, resembling cancer- 
cells, were not numerous. The pus issuing from the large abscess 



MALAEIAL FEVER. 



269 



resembled ordinary pus under the microscope, and contain a few 
of these peculiar cancer-like cells. 
I The spleen of an American^ luho died from ihe formation of lieart- 
I clots ^ consequent upon structural disease of the heart and liver ^ and icho 
had suffered with an attach of malarial fever two years previous to his 
death^ whilst residing upon the Ogeechee Kiver, in a low, miasmatic 
situation, was enlarged and indurated, and presented a purplish-red 
color. When pressed in the hand, it felt dense and firm. When 
cut or torn, the color and structure resembled that of healthy 
spleens in all respects, except that it had a much larger quantity 
of fibrous tissue. The pulp of the spleen absorbed oxygen readily 
when exposed to the atmosphere, and changed to a bright scarlet 
color. The pulp of the spleen presented nothing peculiar under 
the microscope. Did not discover those black flakes and granules 
which were so abundant in the spleen of the patient previously 
described. This spleen contained animal starch. 

It is reasonable to suppose that the enlargement and induration 
of this spleen were the effects of the previous attack of malarial 
fever. During the active stages of the fever the spleen was en- 
gorged with blood, softened, and the trabecula3 in many places 
ruptured. When the action of the malarial poison ceased, the 
serum of the extravasated blood was removed, and the ruptured 
trabeculas repaired, and numerous bands of fibrous tissue formed 
throughout its substance. Finally the colored corpuscles of the 
extravasated blood were disintegrated and removed. 

These cases demonstrate that the alterations of the spleen occur amongst 
the first pathological effects of the malarial poison. 

The gradual enlargement of the spleen in the bodies of those inhabit- 
ing malarious districts^ without any distinctly marked febrile symptoms^ 
shows that these alterations of the spleen may precede the active symp- 
toms^ and those disturbances of the nervous system attending the cold 
and hot stages of malarial fever. 

These cases demonstrate that the alterations of the spleen in 
malarial fever are of the most decided and serious character. The 
spleen might be readily ruptured, either by violent exercise or by 
blows, or even by rough handling, during the active stages of ma- 
larial fever. 

I An immense number of colored blood- corpuscles are destroyed in the 
' spleen during the active stages of malarial fever. The effused colored 
corpuscles are gradually disintegrated ; their hsematin appears as 
dark granular masses, which are gradually altered physically and 



270 



OBSERVATIONS OX 



cliemicallj, passing through several shades of color, and are finally 
eliminated. The serum of the effused blood is also removed ; 
fibrous bands or trabeculas are formed through the extravasated 
blood, the capsule is thickened, and gradually the organ becomes 
firm and assumes its normal structure and offices. 

The cause of the peculiar pathological alterations of the spleen 
in malarial fever appears to depend upon the alterations of the 
blood and circulation, which produced similar congestions in the 
brain and liver, and upon the peculiar anatomical structures of 
the spleen. We have before shown that the fibrin of the blood is 
diminished and altered in malarial fever, and that the relations 
between the general and capillary circulations, and between the 
constituents of the blood and the walls of the vessels, are dis- 
turbed, and that the chemical changes upon which the capillary 
circulation depends are perverted and diminished, and that the 
action of the heart is greatly disturbed. Here, then, we have causes 
sufficient to account for the stagnation of the blood in the import- 
ant organs of the trunk, and especially in the spleen, on account 
of its anatomical relations to the o.ther organs of the abdomen, the 
absence of valves in the splenic veins, and their communication 
with the intercellular spaces of the spleen-pulp. Ish. Gray has 
shown that many of the capillary vessels are not directly continu- 
ous with the veins, but that the blood, in passing from one set of 
vessels to the other, traverses intercellular spaces in the spleen- 
pulp, and that the veins in many cases commence in intercellular 
spaces. 

If these vieics are correct^ it follows as a necessary consequence that 
the j^CL^hohgical alterations of the spleen in malarial fever are not the 
result of inflammatory action. 

The red color of the trabeculae, after the pulp has been washed 
out, has nothing to do with inflammation, and is the result of the 
action of the coloring matter of the disintegrated blood-corpuscles, 
and is analogous in all respects to the staining of the endocardium 
and large vessels by imbibition of haematin, in many diseases en- 
tirely unaccompanied by inflammation. 

Pancreas. 

AYe have been unable to detect any alteration in the pancreas 
peculiar to malarial fever. 



MALARIAL FEVER. 



271 



Kidneys. 

In several cases of malarial fever, and in two which had yielded 
suddenly in the earliest stages, the kidneys presented slate-colored 
spots, which presented a bronze color upon section to the depth of 
one-fourth to one-eighth of an inch. Microscopical examination 
demonstrated that the black granules were not present in these 
bronzed portions, and that the structures of the kidney were not 
altered in any recognizable manner. We have in a previous chap- 
ter* considered the bearing of this fact upon the slate and bronze 
color of the liver. 



CHAPTER YI. 

circulation, respiration, temperature, state of the skin, tongue, 
and changes of the urine in intermittent, remittent, and conges- 
tive fever, 

Principles of Treatment based upon these Observations. 

The complete investigation of pathological phenomena demands 
the accurate determination of the amounts and chemical relations 
of all the materials entering into the diseased body, and of the 
transformations through which these materials pass, and of the 
amounts eliminated, and of the chemical and physical forms and 
conditions under which they are eliminated ; demands the accurate 
determination of the chemical changes of the constituents of the 
organs, tissues, apparatus, and blood, and of the forms and condi- 
tions under which they are eliminated. 

The pathologist has no means of determining the character of 
the chemical changes going on in the living body during the dif- 
ferent stages of disease. 

The pathologist is limited to an examination of the forces deve- 
loped by these changes, and of those products resulting from these 
changes, which are eliminated and cast off from the body. 

Although it is impossible in the present state of science to deter- 



272 



OBSEKVATIONS ON 



mine accurately the amounts of the muscular and nervous forces, 
and of heat generated during the stages of diseases, still an exami- 
nation of the mutual relations and disturbances of these forces 
during the progress of disease, yields invaluable information bear- 
ing upon the nature and treatment of diseases. The amount of 
force generated in the living body, no matter in what peculiar form 
or mode of force it appears, always stands in direct relation with 
the amount of matter chemically altered. The great laws of action 
and reaction, and of the indestructibility of force, apply, as we have 
before demonstrated, to all the forces which v/ork the animal ma- 
chinery. 

We have instituted, and are still prosecuting, a series of experi- 
ments, the object of which is the demonstration that all the forces 
of animals, physical, chemical, muscular, and nervous, are derived 
from the chemical changes of the elements entering into their bodies 
as food, and forming their structures. 

The following observations demonstrate, as far as they extend, 
that the forces of animals are developed by a chemical change of 
the elements, and are proportional to the amount of chemical 
change:— 



MALAEIAL FEYER. 



273 



I- 

8 



o 



5- 

^ ! 



•Ai.moTt 
paja.Toxa anuu 
JO sjnanjijsnoo 
pnosaqj JO ;.raY 


= ^30^^ on—' O 


^■BUtSl.IO 

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eqj JO trouou.ij 
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amjti JO jnnoniv 














■noTi-BA 
-.T'Bjs pni3 is.nq} 
Snunp pajo.TOxa 
eitun JO jTnioray 


£ -ri- ^ f 1 X 


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cx5 06 


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274 



0B5EEYATI0XS OX 



These observations, which I have extended to numerous other 
warm and cold-blooded animals, and to man, together with an exa- 
mination of the structure and development of the circulatory and 
respiratory apparatuses of the animaP kingdom, support the fol- 
lowing conclusions : — 

The intellect, temperature, nervous, and muscular forces, and 
organic development of animals, are in proportion to the rapidity 
of the changes of the elements. In warm-blooded animals, which 
are endowed with intellect of a high order, and possess great nerv- 
ous and muscular force, and correspondingly developed organs, the 
changes in their elements are incessant. T\^hen starved they lose 
weight rapidly. In cold-blooded animals, the temperature of which 
is often below the surrounding medium, and whose nervous system 
and intellect are feebly developed, the changes in their elements 
are correspondingly slow. The cur dog lost in six days and four- 
teen hours one-third of its original weight: whilst the chelonians 
lived from thirty to sixty days without losing more than from one- 
fourth to one-thirteenth of their original weight. The loss in the 
former was from six to fifteen times more rapid than in the latter. 
The loss of weight at the time of death was very nearly equal in 
warm and cold-blooded animals. The maintenance of the short, 
vigorous life of the former required as large a supply of organic 
and inorganic materials as the prolonged existence of the latter. 
T\^hat the warm-blooded animal gained in intensity and power, it 
lost in duration. 

The length of the life of an animal during starvation and thirst, 
is proportional to the rapidity of the changes of its elements, and, 
as a necessary consequence, stands in direct relation to its tempera- 
ture, intellect, and organic development. TTarm-blooded animals 
wasted more rapidly, lived more energetically, and died in a cor- 
respondingly shorter time than cold-blooded animals. Amongst 
cold-blooded animals the chelonians, which were most active in 
their movements, and whose nervous system was most excited, 
lived during a time corresponding with their increased nervous and 
muscular exertions. The female terrapins, whose ovaries and ovi- 
ducts were filled with hard and soft eggs, lost from ^i^^s 3 sVs 

1 For numerous experiments on tMs subject, see tlie antlior's investigations, 
published bv tlie Smitlisonian Institution — " Investigations, Chemical and Phy- 
siological, Relative to Certain American Tertebrata,"' by Joseph Jones, M. D. ; 
Smithsonian Contributions to Knowled^re, 1S56. 



MALAEIAL FEYEK. 



275 



their weight hourly, and died in the course of twenty-five or thirty- 
five days; while the females which had deposited their eggs, and 
the males, which were free from these anxieties, wasted only one- 
half as much per hour — ^^\q to ^^^^^ of their whole weight — and 
lived twice the length of time — from fifty to seventy days. 

As the acts of life are carried on in the same general manner in 
all animals, and as each species and individual has its own peculiar, 
intellectual, and physical endowments, it follows, as a necessary 
consequence, that each species and individual, whether belonging 
to the animal kingdom or to the human race, must have its own 
amount of chemical change, which develops the forces. The forces 
developed by these chemical changes are dependent upon the 
amount of matter chemically altered, and the position and manner 
in which it is altered. Here is a wide and important field for in- 
vestigation, as yet almost entirely untrodden. 

These facts, although imperfect, are sufficient to demonstrate the 
necessity in every pathological investigation, of determining the 
amount of matter chemically altered and thrown off, and the cha- 
racters of the matters thus eliminated. This can only be accom- 
plished by the determination of the amounts and characters of the 
matters thrown off from the lungs, skin, kidneys and bowels. We 
know that it is almost impossible, with the present instruments and 
methods of investigation, to determine accurately, the changes in 
quantity of carbonic acid gas thrown off from the lungs under dif- 
ferent circumstances of health, during long periods of time, and the 
difficulties are greatly increased when we attempt to determine the 
quantity and characters of the excretions of the skin. Any obser- 
vations with the present instruments and methods of investigations 
upon the amounts of matter thrown off from the lungs and skin, 
for long periods during different diseases, must be unsatisfactory if 
not absolutely impracticable. Happily the pathologist can examine 
the urine which reflects as in a mirror, the changes going on in the 
body, and can determine the relations and changes of the animal 
temperature, circulation, and respiration. 

"We hope to demonstrate hereafter, by numerous careful obser- 
vations, that the determination of the relations of the circulation, 
respiration, and temperature in diseases, is of the greatest import- 
ance in enabling the practitioner of medicine to understand the 
nature and treatment of diseases, and predict with a great degree 
of certainty, their course and termination. Thus, whenever, as in 
congestive fever, there is a want of correspondence between the 



276 



OBSERVATIONS OX 



circulation, respiration, temperature, and chemical changes, the 
patient is always in danger. A patient with a rapid feeble pulse, 
and rapid thoracic respiration and low temperature (sluggish chemi- 
cal changes), is always in great danger. A full moderately rapid 
pulse, and moderately rapid and full respiration, and correspond- 
ingly high temperature, are always favorable symptoms, provided 
there be no complications, as congestion of the brain. The severity 
of malarial fever is by no means proportional to the height of the 
fever (animal temperature). As a general rule, the higher the 
fever (temperature), the more readily does the attack yield to treat- 
meut, and the less serious the effects. High temperature signifies 
active chemical changes, and an effort on the part of nature to 
break up and consume the poison, and a power of resistance. It is 
the want of a high temperature which is the most dangerous symp- 
tom in malarial fever. 

It is necessary that we should in the first place establish stand- 
ards of the action of the respiratory and circulatory apparatus and 
of the animal temperature of the different parts of the body in 
health, to which the changes in disease may be referred. 

The following observations are valuable, because they were all 
taken with the same instrument, in the same hospital, and under as 
similar circumstances as I could devise. In their determination 1 
used every precaution necessary to accuracy : — 



MALARIAL FEVER. 277 



Table slioioing the Variations of the Pulse, Respiration, and Temperature 
of Different Individuals. 















'o 


•e of 


S 5d 












o 


P % 




s a 








REMARKS, &c. 












Age. 


Sex. 


Date. 




Pulse. 


to 


s a 


Tempe 
hand. 


Tempe 
undei 


IS 


M. 


July 15 


Healthy, active y.oung man; American; student of 
medicine ; sanguine temperament ; standing pos- 
ture, after exercise. 


78 


20 


82.1° 


99.0" 


9950 
































20 


M. 


July 15 


Healthy young American physician ; sanguine tem- 
perament; standing posture, after exercise. 


68 


20 


S2.0 


98.0 


99.5 


12 


M. 




Negro boy, healthy and active ; erect posture, after 
exercise. 


88 


21 


82.0 


97.0 


99.5 


2i 


M. 




Healthy, active young man ; lying in bed just after 
waking in the morning. 


76 


15 


45.0 


95.0 


98.0 


22 


M. 


Oct. 5 


Seaman ; during convalescence from intermit, fever. 


62 


21 


70.0 


96.0 


99.. 33 


27 


M. 




English seaman ; recumbent posture. 


64 


16 


78.0 


9S.0 


99.0 


2.5 


M. 




Irish seaman ; recumbent posture. 


60 


17 


S3.0 


97.0 


98. 8 


25 


M. 




Seaman; recumbent posture; during convalescence 
from remittent fever. 


44 


22 


84.0 


97. S 


99.12 


14 


M. 




Irish seaman ; recumbent posture. 


57 


16 


81.0 


9S.0 


99.5 


44 


M. 




Baker and cook ; right arm and leg somewhat pa- 
ralyzed. 






82.0 


99.0 


100.2 


26 


M. 


Sept. 25 


Stout Amei'ican seaman. 


62 


14 


76.0 


98.0 


99.25 


26 


M. 


Oct. 8 


Do. do. 


48 


14 


73.0 


97.0 


99.5 


23 


M. 


Oct. 9 


Do. do. 


43 


15 


72.0 


96.5 


99.75 


20 


M. 




English seaman; shortly after recovering from an 
attack of intermittent fever. 


72 


17 


84.5 


98.7 


99.9 


30 


M. 


July 6 


American seaman ; slight paralysis of one hand, but 
otherwise healthy. 






88.0 


96.5 


99.0 


30 


M. 


July 9 


Do. do. do. 






81.0 


97.5 


99.0 


27 


M. 


July 6 


Portuguese sailor; suffering from injury of spine; 
health otherwise good. 






79.0 


98.5 


99.0 


27 


M. 


July 9 


Do. do. do. 






83.0 


98.0 


99.0 


50 


M. 


July 7 


Stout English seaman. 






81.5 


96.0 


99.7 


20 


M. 


July 9 


Do. do. 




16 


81.5 


9S.0 


98.9 


48 


M. 


July 1 


American; stout, well built; suffering with partial 
paralysis of right side; health otherwise good. 






82.5 


9G.0 


99.2 


24 


11. 




Irish laborer. 






82.0 


98.0 


99.25 


30 


M. 


Juiy 8 


Irish laborer; paralysis of right leg from blow, but 
otherwise healthy. 






80.0 


98.0 


99.5 


IS 


F. 


July 15 


Stout Irish woman ; subject to fits of partial insanity; 


84 




79.0 


92.0 


98.0 






apparently in perfect health. 












30 


F. 


Aug. 7 


American woman ; superior portion of body in per- 
fect health ; chest and arms well developed ; lower 
extremities atrophied ; general health good. 






80.5 


97.5 


100.1 


45 




Oct. 19 


American seaman in erect posture, after walking. 


20 


60 


71.5 


96.0 


99.0 



The following tables are drawn up from the observations of Dr. 
John Davy, w^hose elaborate and valuable researches afford the best 
materials for the establishment of the limits of the variations of the 
pulse, respiration, and temperature in health: — 



278 



OBSERVATIONS ON 



Variation of Temperature during 24 hours. Mean of Daily Observa- 
tions for one year in England and one year in Barhadoes. By John 
Davy, M. D.^ 



Mean Temp, under Tongoe. 


Pulse. 


Kespirations. 


Temperature of Koom. 


7-8 
A. M. 


3-4 
P. M. 


12 
P. M. 


7-8 
A. M. 


3-4 
P. M. 


12 
P. M. 


7-8 ] 3-4 
A. M. P. M. 


12 
P. M. 


7-8 
A. M. 


.3-4 
P. M. 


12 
P. M. 


98.743 


98.52° 


97.92° 


57.6 


55.2 


54.7 


15.6 15.4 


15.2 


50.9° 


54.7° 


62.0° 


In Barbadoes — 


Mean Temp, under Tongue. 


Pulse. 


PlESPIRATIONS. 


Temperature of Eoom. 


6-7 
A. M. 


12-2 
P. M. 


9-11 
P. M. 


6-7 
A. M. 


12-2 
P. M. 


9-11 
P. M. 


6-7 
A. M. 


12-2 
P. M. 

15.4 


9-11 
P. M. 


6-7 
A. M. 


12-2 
P. M. 


9-11 
P. M. 


98.07° 


98.9° j 99.0° 


54.4 


56.0 


60.3 


14.4 


15.0 


76.7° 


83.6° 


79.0° 



Variations of Temperature dmnng different Seasons of the Year. 
By John Davy, M. D.^ 



Month. 


Mea n temp, 
under 


Air of 


Month. 


Mean temp, 
imder 


Air of 


tongue. 


room. 




tongue. 


room. 


1845 






1847 






July .... 


98.43° 


76.00° 


January . . . 


98.60° 


77.70° 






80.60 


February . . . 


98.53 


80.26 


September . . 


98.60 


81.20 


March . . . 


98.60 


77.40 


October 


98.58 


81.46 


April .... 


98.53 


78.00 


November . . . 


98.46 


80.56 


October . . 


98.66 


80.83 


December . . . 


98.40 


77.90 


November . . . 
December . . 


98.56 
98.36 


79.66 
77.36 


1846 






1848 






January . 


98.63^ 


78.16 


January . . 


98.60 


77.06 


February . . . 


98.60 


77.88 


February . . . 


98.53 


77.73 


April .... 


98.46 


80.00 


March .... 


98.60* 


78.40 


May .... 


98.66 


81.50 


April .... 


98.60 


78.26 


June .... 


98.66 


81.56 


May .... 


98.66 


81.46 


July .... 


98.36 


81.00 


June .... 


98.60 


80.86 


August .... 
September . . 


98.70 


81.60 


July .... 


98.36 


80.46 


98.40 


81.36 


August .... 


98 76 


81.56 


October . . 


98.73 


81.50 


September . . 


98.76 


82.26 


November . . . 


98.60 


80.60 


October . . . 


98.76 


81.50 


December . . 


98.63 


77.96 


November . . . 


98.60 


79.83 








Mean entire series 


98.54 


79.75 ' 



' Phil. Trans., part ii. 1850, p. 437. 
2 Ibid. 



MALARIAL FEVER. 



279 



Table showing the Variable Temperature of Man. Drawn up from 
Observations on Seven Healthy Meyi, during a Voyage from England 
to Ceylon. By John Davy, M. D. 



Age. 


Temperature under 
tongue. 
March 10th. 
Temp, of air, IS'^. 


Temperature under 
tongue. 
March 2d. 
Temp, of air, 79.. 5°. 


Temperature under 
tongue. 
April 4th. 
Temp, of air, 80°. 


Temperature under 
tongue. 
May 5th. 
Temp, of air, 30°. 


24 


99.00° 


100.00° 


99.50° 


98.50° 


28 


99.50 


99.50 


99.50 




25 


98.75 


98.50 


99.75 


98.25 


17 


99.00 


99.00 


100.00 




25 


99.00 


99.00 


99.50 


98.00 


20 


98.00 


99.50 


100.00 


98.75 


28 


98.75 


99.00 


99.50 


98.25 



280 OBSEEVATIONS ON" 



o 



CO 



2 



2^ o 



e.iuj'B.iodaiajj 



8.iiijB.iadma^]j 



2 a 

si CD 



•xag 



So 

Is 



8jn}u.i3duiax 



o 


'O 


O 




o 




CO 

02 


CO 
Oi 


Oi 


05 


Ol 






05 
05 




CO 




CO 



s s s s 



■au§uo:> .lopnn 



CO 03 

C5 a> 



CO (M i-l 



s s s s 



Africans. 

Servants in military- 
hospital at Kandy. 

Dec. 17th. 
Temp, of air, 74°. 


9.in:H3.iediuoj, 


o 
98.0 

98.0 

98.0 

98.0 

98.0 


•enSao} japun 
o.iu^Ti.iadiuojj 


o 
98.0 

98.5 

99.0 

99.5 

99.5 


•oSy 


CO "O »o ^ OO 
(M CO <N CO (N 


•xos 


S : : : : : 


o a 


o.mjTJ.iodraax 


o 
95.0 

96.0 

96.0 


•onSno} .lapnn 

9.lU)-B.I8dUI8J, 


o 
98.0 

98.0 

98.5 


•oSy 


O O 'O 
CD CO CO 


•X9S 


S S : : '.' 


Half Caste Singalese 
Children. 

Ceylon, Oct. 12th, 

6-7 A. A. 
Temp, of air, 78°. 


o.ini'Biodrasjj 


o 

98.5 

100.0 
99.5 
99.0 


•onSnoj .Topun 
©.inj-ejodmoj, 


o 

100.5 
100.1 
100.0 
102.0 

101.5 
100.0 


•oSv 


(M ^ t~ O ^ 


•xog 


f:=; F^; s g 


Albinos (Sin- 
galese). 

Ceylon, Sept. 

Tem. of air, 79°. 


•eni?noi .lopnn 

OJUJB.iedUTOJj 


o 

101.5 
101.5 
101.75 
101.0 




lO <N CO 

rH CM 


•xog 


pq fj^' pI^ S ■ • 


Singalese. 

Island of Cey- 
lon, Sept. ]4tb. 
Tem. of air, 79°. 


•onSnoj jgpnn 
8anfB.i9dai8x 


O 'O o o o o 
o i-H i-I t-H i-I d d 
o c o o o o 


•oSy 


O CS 00 O 'O 

o cq -j< 


•xos 


Ptj Pm S S S ^ 


O P.hS<^ fi 

HH TO W <D 


•enSuo; .lopnti 
o,ai;i3.iodaiojj 


o 
9S.0 

96.5 

96.5 

97.75 

99.5 



MALARIAL FEVER. 



281 



Table of Observations on the Temperature of the Insane in the Winter 
and Summer o/1838. By John Davy, M. D.^ 



Age. 


Species of 
insanity. 


Winter. 


Summer. 


State of health. 


Temperature 
under 
tongue. 


State of health. 


Temperature 
under 
tongue. 


55 


Amentia 




100.0° 




101,0° 


63 


Mania 


KXOOd 


J.UU. V 


Good 


101.5 


49 


Mania 


vjruou. 


TOO 0 


Good 


101.0 


31 


Amentia 


Rather feeble 






101.0 


41 


Mania 


Grood. 


98.0 


Good 


101,0 


42 


Amentia 


Good 


99.0 


Good 


100.5 


50 


Amentia 


Gl 1 /vTi + 1 XT* nilinifr 

OligSlLlj' driilllg 


102.0 


Good 


99.5 


62 


Amentia 


Good 


98.0 


Good 


100,5 


69 


Amentia 


X tJcUit} 


100.0 


J? tJt? Uio 


101.0 


51 


Amentia 


i: Ltsiiy gvJuu. 


99,0 


iVlULltJl ct It! 


100.0 


34 


Amentia 


JTlclty guuti 


100.0 


iVl U Ll c 1 d \A3 


101.0 


53 


Amentia 




99.0 


Good 


101.0 


37 


Mania 


finnri 
vjruuu. 


99.0 




100.0 


41 


Mania 




101 0 


OViGi^nvfi /lies.. 


104.5 










ease of lungs 




41 


Amentia 


Pretty good 


99.0 


Good 


100.0 


64 


Mania 


Good 


101.0 


Good 


101.0 


45 


Amentia 


Prettj good 


100.5 


Moderate 


101.0 


29 


Amentia 


Indifferent 


99.0 


Indifferent 


99.0 


57 


Mania 


Good 


99.0 


Good 


100.0 


61 


Melancholia 


Good 


100.5 


Good 


101.0 


40 


Amentia 


Good 


100.0 


Good 


101.0 


61 


Amentia 


Good 


98.0 


Good 


100.0 


47 


Amentia 


Good 


101.0 


Good 


101.0 


27 


Amentia 


Good 


98.0 


Good 


100.0 



Before proceeding to record the results of our investigations, it 
is necessary that I should state the methods by which the tempera- 
tures, pulse and respiration were determined, and the difficulties and 
imperfections of the investigation of the changes of the urine. 

The pulse and respirations in the following investigations were, 
unless stated otherwise, always determined in the recumbent posture. 

All the temperatures recorded were determined by the same in- 
strument, which was carefully constructed, and was upon compa- 
rison with standard instruments found to be accurate. 

The thermometer was always allowed to remain under the tongue, 
in the hand, or in the armpit, for some time after it was station- 
ary, and all the observations were taken and recorded at the bed- 
side, under my own hand and eye. The greatest care was exercised 
in determining the temperature; the patients were in all cases, un- 
less stated otherwise, lying quietly in bed, and protected from all 
currents of air. 

' Physiological and Anatomical Researches, vol. i. p. 204. 

19 



282 



OBSERVATIONS ON 



The importance of attending to these circumstances, is strikingly 
illustrated by the following experiments which I performed upon 
myself. 

Athens, Jan. 23d, 6 o'cock A. M. Lying in bed, just after wak- 
ing from sleep. Pulse, 76; respirations, 15. Temperature of air of 
chamber, 45° F. ; temp, of exterior air, 28 ; temp, of hand, 95 ; 
temp, under tongue, 98. Dressed myself and took a walk of two 
miles over several hills, in thirty minutes. The ground was frozen 
and covered with frost. During the walk, my hands were bare 
and freely exposed to the atmosphere. At first, the sensation of 
cold was unpleasant, but towards the end of the walk, reaction ap- 
peared to take place, and they felt much warmer. Pulse, 90; respi- 
rations, 20. Temperature of atmosphere, 30° F.; temp, of hand, 78; 
temp, of axilla, 98. 

During the walk, the pulse had gained 14, and the respiration 5, 
to the minute. The temperature in the hand had fallen 17°, whilst 
that in the axilla had remained stationary. The respiration in bed 
was gentle and regular. The respiration after walking in the cold 
was accelerated, full and vigorous. Here we see that a diminution 
of the temperature upon the exterior was attended by a corre- 
sponding change in the movements of the circulatory and respira- 
tory systems. They became more active in order to receive and 
distribute more rapidly the oxygen, and remove with corresponding 
rapidity the. increased products of the increased chemical changes. 

It is also worthy of note that the increased circulation and respi- 
ration were not attended with a rise of temperature, because the 
radiation of heat from the surface of the body more than balanced 
the increased generation of heat consequent upon the increased 
chemical change. 

I took breakfast, and then walked three miles over several hills, 
in forty minutes. My hands were kept in the overcoat pocket 
during the walk. At the end of the walk, the following were the 
results observed : Pulse, 88 ; respirations, 26. Temperature of 
atmosphere, 45° F. ; temp, of hand, 97 ; temp, under tongue, 98.5. 

January 24th, 4 o'clock P. M. After sitting and writing for 
several hours in a cold room, without fire, my right hand, which 
was freely exposed moving over the paper, felt very cold and stifi*. 
Pulse, 76 ; respirations, 16. Temperature of atmosphere, 48°; temp, 
of right hand, 75 ; temp, in axilla, 98.5. In this experiment the 
right hand lost 22° in the course of two hours. 

These experiments demonstrated conclusively the absolute neces- 



MALARIAL FEVER. 



283 



sity of adhering rigidly to a uniform method of ascertaining the 
pulse, respiration and temperature in health and in disease. 

In comparative investigations, the truth will not be obtained 
without the most scrupulous and unremitting attention to the posi- 
tion of the patient, and all the surrounding circumstances. 

Before presenting the results of numerous analyses of the urine 
in the different forms of malarial fever, we would candidly ac- 
knowledge the sources of error in determining the^amount of urine 
excreted during any stated period, as twenty-four hours. 

When the bowels are frequently moved, it is almost impossible 
to ascertain, even approximately, the amount of urine excreted. 

When the patient is delirious, and passes his urine and feces in the 
bed, it is impossible to ascertain either the amount or character of 
the urine. Even when the bowels are not moved, and the patient 
retains his faculties and a considerable amount of strength, it often 
happens that, during the night, the nurse will neglect to attend to 
the passage and preservation of the excretions in the proper vessels. 
It often happens, from a combination of these circumstances, that 
the urine of the most fatal, important and interesting cases, escapes 
our examination. These difficulties in hospital investigations can- 
not readily be overcome, and will often invalidate the conclusions 
drawn from individual cases. 

Our duty, then, is to obtain as wide an induction of facts as pos- 
sible, and thus eliminate or equalize, as far as possible, the errors, 
and draw our conclusions not so much from individual cases as 
from the whole assemblage of facts. 

From our copious notes on more than two hundred cases of 
malarial fever, we have determined to present a condensed state- 
ment of only those facts which present points of interest to the 
physiologist, pathologist and practitioner of medicine, and will 
often refrain from noticing the full bearing of these facts, because 
our limits would not allow of extended discussions. 

Our limits will not permit us to enter into a minute account of 
the method of analyzing the urine. In view of the numerous ex- 
cellent treatises, accessible to all, this would involve an unnecessary 
consumption of space and time. 

The urea^ was separated in the form of the nitrate, and every 

* Lelimann's Physiological Chemistry, Eng. ed., vol. i. p. 159 ; Am. ed., vol. i. p. 
149. Mitscherlicli in Annalen der Physik und Ghemie, Von Poggendorff, bd. 31, s. 
303. " Kidneys and Urine," by J. J. Berzelius, translated by Boyle and Leaming, 
M. D. Phila., 1843, pp. 66-83. " Handbook of Chemistry," by Leopold Gmelin, 



284 



OBSEKVATIONS ON 



care was taken to secure accuracy in the results. The amount of 
the constituents in all these analyses, from the causes previously 
stated, will be underrated and never overrated. 

The urine was always analyzed a short time after its passage. 
This precaution is necessary in a warm moist climate like that of 
Savannah. In the heat of summer, the urea is often, especially in 
the urine of convalescence, rapidly decomposed into carbonate of 
ammonia. In one case of malarial fever, where the patient was 
sufiering with a stricture and irritation of the bladder, every trace 
of urea disappeared from the urine in twelve liours. 

I have endeavored scrupulously to exclude from these papers 

translated by H. Watts, Cav. Soc. pub. London, 1852, vol. vii. p. 363. Simon's 
Chemistry of Man. Phila., 1846, p. 397. Becquerel and Rodier's Pathological 
Chemistry, translated by Speer. London, 1857. See also for the general analysis 
of the urine, "Anleitung zur qualitativen und quantitativen Zoochemischen Ana- 
lyse." Von E. Von Gorup Besanez. Niirnberg, 1854. " Anleitung zur qualitativen 
und quantitativen Analyse des Hams." Von Carl Neubauer. Wiesbaden, 1854. 
Heintz, Lehrbuch der Zoochemie. Berlin, 1853. Schlossberger, Lehrbuch der or- 
ganischen Chemie, mit besonderer Riicksicht auf Physiologie und Pathologie. 
Stuttgart, 1854. Robin et Verdeil, Traite de Chimie Anatomique et Physiologique, 
ou des Principes immediats Normaux et Morbides que Constituent le Corps de 
I'Homme et de Mammiferes, 3 vols. Paris, 1853. "A Course of Practical Chem- 
istry," arranged for the use of Medical students, by Wm. Ordling, M. D. London, 
1859. "Bird on Urinary Deposit." Phila., 1854. Bowman's Medical Chemistry. 
Phila., 1855. 

For Liebig's valuable Memoir " On Certain Urea Compounds, and a new method 
of determining the Chloride of Sodium and the Urea in the Urine," see Ann. der 
Chem. und Pharm., vol. Ixxxv., pp. 289-328. See translation of this Memoir in 
vol. vi. of the Quarterly Journal of the Chemical Society. Limpricht, "On the In- 
fluence of Allantoin on the determination of Urea, by the method of Liebig," Ann. 
der Chem. und Pharm., vol. Ixxxvii. p. 99. Kletzinsky, "On the Comparison of 
the Values of the Di£Ferent Methods of Determining the Quantity of Urea," Heller's 
Archiv. fiir Chem. und Mikrosk., p. 252. Jahrgang, 1853. 

"A new Method of Determining the Amount of Urea," by Dr. E. Davy. Phila. 
Mag., June, 1854 ; Medico-Chir. Rev., Oct., 1854. " The Detection and Estimation 
of Urea," by Ragsky, Ranking's Abstract of Med, Sciences, 1845. Part ii. p. 90. 
Beitrage zur Kenntniss der Urinabsonderung bei gesunden, schwangern und kran- 
ken Personen. Inaugural Abhandlung von Friedr. Mosler. Giessen, 1853. Kli- 
nische Untersuchuugen iiber den Stoffwechsel bei gesunden und kranken Menschen 
iiberhaupt, und durcli den Urin insbesondere. Von Prof. J. Vogel. GSttingen, 
1853. "Studien zur Uroligie." Von Dr. F. Fr. Bencke (Archiv. des Vereins fiir 
gemeinschaftliche Arbeiten, Band i., Hefte 3, 4). Gottingen, 1853. 

Beitrage Zu Kenntniss der Urinabsonderung bei gesunden Inaugural Abhand- 
lung von Aug. Winter. Geissen, 1852. 

" A Treatise on the Pathology of the Urine," by I. L. W. Thudichum, M. D. 
London, 1858. 

Beale's Archives of Medicine, No. 1, pp. 34-42 ; No. 2, pp. 142-1-17. 



MALARIAL FEVER. 



285 



every analysis, the result of which was influenced by changes in 
the urine, subsequent to its excretion by the kidneys. Uric acid 
was determined in the usual manner. The inorganic fixed saline 
matters were determined according to the method of M. Lecanu. 

1. INTERMITTENT FEYER. 
Cold Stage. 

Proposition I. During the cold stage {chill) there is a rapid^ feehle 
pulse, fuUj rapid respiration, and a hot trunk and cold extremities. 

During the rapid thoracic respiration oxygen is supplied in 
abundance, and enters into the blood, which is confined during the 
cold stage almost entirely to the trunk and large organs. The 
amount of oxygen received, and the elevation of the temperature 
of the trunk, will depend upon the capillary circulation of the 
lungs and large organs of the trunk, and upon the action of the 
heart. 

Proposition II. During the cold stage the temperature of the extre- 
mities is reduced far heloiv that of the trunk, and even below the standard 
of health, because the circulation of the blood in the bloodvessels and 
capillaries is feeble. 

The surface of the trunk and extremities presents a mottled pur- 
plish color during the cold stage, because, the supply of oxygen 
being greatly diminished, the change from the venous to the arte- 
rial hue does not take place. 

The shivering and twitching of the muscles during the chill are 
excited in a manner analogous to the shivering produced by 
exposure to cold. "When the temperature of the extremities is 
rapidly reduced by rapid radiation, the capillary circulation becomes 
feeble, the surface presents a wrinkled and often bluish appearance, 
the blood is not furnished in sufficient quantities to supply the ele- 
ments of nutrition and chemical change in the muscles and nerves, 
the chemical actions of both the muscles and nerves are diminished 
and perverted, and, as a necessary consequence, this diminution 
and perversion of chemical change is attended by aberrated mus- 
cular and nervous action. 

The phenomena of diminished capillary circulation, and corre- 
sponding diminution in the supply of nutritive materials, and ele- 
ments of chemical change, and reduction of temperature, may be 



286 



OBSERVATIONS ON 



also produced by derangement of the general circulation and de- 
rangements of the sympathetic nervous system. In both cases 
the cause of the diminished temperature in the extremities would 
be due to feeble capillary circulation. In both cases the cause of 
the aberrated muscular and nervous phenomena would be due to 
diminished and perverted chemical changes. 

That the chemical changes are perverted during this state of 
reduction of animal temperature and diminution of capillary cir- 
culation is conclusively demonstrated by the fact that in congestive 
fever, where we have, as it were, a permanent reduction of tempera- 
ture, and arrest of capillary circulation, and diminution of chemical 
change, both in the trunk and in the extremities, the products 
resulting from these perverted chemical changes are far different 
both from those of health and those of fever, when the system 
reacts. 

• Proposition III. The diminution of the capillary circulation and 
reduction of the temperature of the extremities precede the aherrated 
nervous and muscular phenomena denominated chill. 

This fact corresponds to the changes in the blood, and demon- 
strates conclusively that the first phenomena of the cold stage are con- 
nected with the sympathetic nervous system. 

Proposition IY. The higher the temperature of the trunk during 
the cold stage, the more rapid ivill be the equalization of the circulation 
and temperature. 

These propositions are sustained by the following cases : — 
(a.) Seaman, aged 55; height 5 feet 4 inches; small, spare man. 
Has been in the hospital several months, suffering with an affection 
of the eyes. This case of intermittent fever originated in the hos- 
pital. 

Chill came on one hour ago ; he is still shaking violently, and his 
lips and hands look blue. Pulse 100, feeble, small. Eespiration 
86 to 50, varies with each quarter of a minute; irregular, thoracic, 
labored. Temperature of atmosphere, 71.5° P.; temp, of hand, 92°; 
temp, under tongue, 104°. 

(h.) Seaman, aged 38; height 5 feet 8 inches ; light hair, blue eyes, 
sallow complexion ; looks as if his liver was out of order. Says 
that he has had chills off and on from the 16th of July to the pre- 
sent time, October 12. Ilis first attack of intermittent fever was 



MALARIAL FEVER. 



287 



contracted in the swamps of the Peedee River, South Carolina. 
Tongue clean and pale ; lips pale, anaemic. This patient presents 
the true malarial hue, and his blood is deficient in colored corpus- 
cles. In the present attack of intermittent fever he has a chill 
every day. 

October 12. This morning had a chill, followed by hot fever. 
During the febrile excitement his pulse was 108 and his respiration 
32 to the minute. As soon as the fever remitted, twenty grains of 
sulphate of quinia were administered. The sulphate of quinia de- 
layed the chill. It did not appear at the regular hour on the 13th 
inst., but came on at 4 o'clock P.M. on the 14th inst. At this time 
I commenced the examination about fifteen minutes after the com- 
mencement of the chill. 

Lips and fingers pale, and of a bluish color; extremities cold, 
whilst the trunk is hot to the touch. Patient is shaking all over. 
Pulse 92, feeble ; respiration 32, full and labored. Temperature of 
atmosphere, 77.5° F.; temp, of hand, 91°; temp, under tongue, 103°. 

A small amount of urine was excreted at the close of the cold 
stage and commencement of the general elevation of temperature 
(equalization of the actions of the general and capillary circulation), 
which had a normal color. Specific gravity, 1023. Reaction de- 
cidedly acid. One thousand parts contained — urea 21.825, uric 
acid 1.467, fixed saline constituents 7.436. 

During the sweating stage, the reaction of his skin was neutral ; 
as a general rule, I have found it to be acid in the various forms of 
malarial fever. Reaction of saliva, as usual, acid. 

October 15, 1859. Complete intermission of fever. Pulse 80, 
fuller; respiration 20, regular. Temperature of atmosphere, 71.5° 
P.; temp, of hand, 96°; temp, under tongue, 98°. 

(c.) Frenchman, aged 45 ; brown hair and eyes ; height 5 feet 7 
inches ; weight 130 pounds. Thin, spare man. Had an attack of 
intermittent fever, commencing September 15. 

This case was treated in the Savannah Poor-house, and yielded 
to the ordinary remedies, and the patient was discharged in the 
course of ten days. He returned to a miasmatic situation, and was 
again attacked with intermittent fever. 

Entered the hospital and poor-house October 7, and stated that 
for the last four days he had had "dumb ague," which came on 
every day at the same hour (11 o'clock A. M.), and lasted two 
hours. A purgative, followed by twenty-five grains of sulphate of 



288 



OBSERVATIONS ON 



quinia, was administered. This delayed the "dumb ague" until 
October 9, 8J o'clock P. M. (twenty-eight hours). 

Examination commenced half an hour after the commencement 
of the "dumb ague." Lips and fingers purplish; extremities cold; 
head and trunk warm. Complains greatly of the sensation of cold, 
but shakes far less than in the former cases recorded. Pulse 92, so 
feeble that it is with difficulty felt, and with still greater difficulty 
counted. The vibrations of the pulse resemble those of a fine 
thread. Eespiration accelerated and irregular. Temperature of 
atmosphere, 75° F.; temp, of hand, 83 ; temp, under tongue, 101.5. 

6J o'clock P. M. Reaction has taken place, and he now has 
fever. Pulse 96, much fuller than during the chill, but weaker 
than in a frank open case. Temperature of atmosphere, 70°F. ; 
temp, of hand, 101.75; temp, under tongue, 102.75. In this case, 
which was far more serious than the preceding cases, we observe 
that the temperature of the trunk was not so much elevated during 
the chill, nor during the subsequent reaction. 

The urine indicated serious disturbances; it was of a high color 
and specific gravity, and correspondingly rich in urea and extrac- 
tive matters. The uric acid was slightly increased. 

Oct. 10th. Intermission of fever. Temperature of atmosphere, 
70° P.; temp, of hand, 97.5; temp, under tongue, 98.5. 

{d.) Irishman; black hair; black eyes; height 5 feet 10 inches; 
weight 130 lbs. In health florid complexion. Has been suffering 
with intermittent fever for four days; chills have been slight. The 
present chill (Sept. 23d, 1857) is slight. Temperature of atmo- 
sphere, 79°F.; temp, of hand, 90; temp, under tongae, 102. 

(e.) >Se(rrm(m; Englishman; brown hair; brown eyes; florid com- 
plexion in health, now his complexion is anaemic; weight 146 lbs.; 
age 25; height 5 feet 6 inches. Sept. 10th. Entered the Savannah 
Marine Hospital, with bilious remittent fever, and from this date 
until the 19th inst. w^as extremely ill. This patient recovered so 
as to be able to walk about the hospital yard. Notwithstanding 
the administration of tonics and iron, his complexion was pale, 
anaemic, and he complained of a severe and continued pain in his 
head. 

On the 4th of October, he was taken with severe chill, followed 
by high fever. This returned every day. 

Oct. 6th. The chill has been on him one hour, and the hot stage 
is just coming on. Pulse 110, feebler than after the complete re- 
action, but stronger than during the lowest depression of the cold 



MALARIAL FEVER. 



289 



stage. Respirations irregular, thoracic, panting, from 40 to 50. 
Muscles trembling violently. Temperature of atmosphere, 70°F. ; 
temp, of hand, 97; temp, under tongue, 104. 

(/.) Irish laborer; stout, well formed man ; sanguine temperament; 
light hair ; blue eyes ; florid complexion ; height 5 feet 9 inches ; 
weight 190 lbs. This is his second attack of chill and fever this 
season. 

Sept. 18th, 11 A. M. Chill is now just going off. Pulse, 112; 
respiration, 28. Temperature of atmosphere, 90.5° F.; temp, of 
hand, 100; temp, under tongue, 104. 

19th, 2 P.M. Apyrexia complete. Pulse, 68; respiration, 24. 
Temperature of atmosphere, 91° F.; temp, of hand, 97.5; temp, under 
tongue, 99. 

Recovered from this attack. Commenced work upon a steam- 
tug, and slept on board in the Savannah River, at night. Returned 
to the hospital with a third attack of intermittent fever. 

Oct. 2d, 2 P. M. Has a chill, and is shaking violently. Pulse 
120, in sitting posture. Respiration 22, in sitting posture. Tempe- 
rature of atmosphere, 79° F.; temp, of hand, 89 ; temp, under 
tongue, 102.25. 

8d, 2 P. M. Has high fever. Pulse, 100 ; respirations 26, full. 
Temperature of atmosphere, 77.5° F.; temp, of hand, 105; temp, 
under tongue, 106. 

Oct. 4th, 2 P. M. Apyrexia complete. Pulse, 58 ; respiration, 
20. Temperature of atmosphere, 76° F.; temp, of hand, 96.5; temp, 
under tongue, 98.5. 

{g.) Seaman: Age 22; height 5 feet 4 inches; weight 140 lbs.; 
black hair and florid complexion; sanguine, nervous temperament; 
native of New York. 

Sept. 29th, 1857. Entered the Savannah Marine Hospital, with 
intermittent fever. Has never been sick before in his life. Has 
been in Savannah two weeks, and this is his first visit. Says that 
he was taken sick, four days ago, with chill, vomiting, and pains 
in all his bones, and has had a chill every day since, commencing 
regularly at 12 o'clock M. Had a chill this day, commencing a 
few minutes after 12 o'clock M. Says that he took three blue pills 
and castor oil, night before last. This medicine operated twice. 

7 o'clock P. M. Has fever, and complains of pains in his joints. 
Slight tenderness upon pressure of epigastrium. Tongue clean, 
moist, red at tip and edges ; papillae enlarged and of a bright red 
color. Reaction of saliva decidedly acid. Pulse, 120 ; respiration 



290 



OBSERYATION'S ON" 



32, full, thoracic. Temperature of atmosphere, 79° F. ; temp, of 
hand, 108.83 ; temp, under tongue, 106. 

R. — Calomel gr. xij ; sulphate of quinia gr. vij. Mix and adminis- 
ter immediately, and follow with castor oil in four hours. As soon 
as fever remits, give sulphate of quinia gr. v, every three hours, np 
to gr. XXV. During fever, give soda powders (pulveres efierves- 
centes tartarizati). Diet, gruel and flaxseed tea. 

80th, 1 o'clock P. M. Medicine operated freely, and says that 
he is much better, but complains of weakness. Tongue presents 
the same appearance; skin cool and relaxed; face not so much 
flushed. Pulse 70, regular; respiration 22, regular and gentle. 
Temperature of atmosphere, 68° F. ; temp, of hand, 92 ; temp, under 
tongue, 99.5. Here we see, that although the pulse and respiration 
are more rapid than in health, the temperature of the trunk is nor- 
mal, whilst the temperature of the extremities is 6° below the nor- 
mal standard, and there is no shaking of the muscles. 

Color of the urine, light orange, sp. gr. 1009. Eeaction decidedly 
acid. Uric acid in grs. 23,220 of urine passed during the last 18 
hours, gr. 1.0035. Uric acid in grs. 30,952 of urine calculated for 
24 hours, gr. 1.3876. Up to this time, 1 o'clock P. M., has taken 
20 grs. of the sulphate of quinia, and the marked diminution of 
the uric acid may be connected with the action of this medicine. 

5 o'clock P. M. Half an hour ago was taken with chill and vomit- 
ing. Now the chill appears to be subsiding, the shaking and con- 
traction of the muscles are diminishing. Extremities cool, whilst 
the head and trunk are pungent to the hand. Pulse 108, feeble , 
respiration 30, full, labored, panting. Temperature of atmosphere, 
74° F.; temp, of hand, 91; temp, under tongue, 105.5. In three 
hours and a half the pulse has increased 38 beats in the minute ; 
the respirations have increased 8 in the minute ; the temperature of 
the extremities has diminished, whilst that of the trunk has in- 
creased 6°. The comparison of this observation with the preceding one 
three hours ago^ demonstrates the truth of the Sd proposition, viz: the 
diminution of the capillary circulation, and reduction of the tempera- 
ture of the extremities, precedes the aberrated nervous and muscular 
phenomena, denominated chill. 

8J o'clock P. M. Three hours and a half after the observation 
upon the chill, the relations between the temperature of the trunk 
and extremities have been restored, and the shaking and shivering 
of the muscles, and the sensation of cold, have vanished. Pulse 
108, fuller and stronger; respiration 32, not so full and labored as 



MALABIAL FEVER. 



29i 



during the chill, but still much fuller and more labored than during 
health. Temperature of atmosphere, 73° F.; temp, of hand, 103.5; 
temp, under the tongue, 105. 

Specific gravity of urine excreted during the cold stage and com- 
mencement of the hot stage, 1020. Color normal. Eeaction de- 
cidedly acid. Uric acid in 5100 grs.of urine excreted during 8 hours, 
grs. 2. Uric acid in 15,300 grs. of urine calculated for 24 hours, 
grs. 6. The uric acid has increased in amount during the chill 
and commencement of the fever, when compared with the former 
specimens of urine ; it is, however, still below the standard of health. 
If the diminution of the amount of uric acid be due to the action of 
the sulphate of quinia, it shows that this action of this remedy 
pointed out by Eanke,^ is not necessarily attended by a disappear- 
ance of the chill. 

Oct. 1st, 11 o'clock A. M. Apyrexia; says he is better and has 
no pain except a slight headache, and was in a perspiration all 
night. Fever intermittent at 12 P. M. Skin cool. Pulse, 76 ; res- 
piration, 23. Temperature of atmosphere, 70° F.; temp, of hand, 95 ; 
temp, under tongue, 98.5. Has taken 15 grs. of sulphate of quinia 
since the intermission of the fever. 

(h.) Englishman, entered the Savannah Marine Hospital, Oct. 9th, 
1857; age 27. Has been in America thirteen years. Height 5 
feet 10 inches ; weight 145 lbs. ; muscular system well developed ; 
sanguine temperament ; occupation, steward on ship ; has been in 
Savannah three weeks. Says that he was taken yesterday at 12 
o'clock M. with cold feelings and headache. The chilly feelings 
lasted four hours, and were succeeded by fever, which continued 
until 4 o'clock this morning. Two and a half hours after the sub- 
sidence of the fever (8J o'clock A. M.) he shook violently. This 
chill was followed by fever. 

Now, 8 o'clock P. M., fever is subsiding. Pulse 98, full but soft. 
Temperature of atmosphere, 72° F.; temp, of hand, 102.5 ; temp, 
under the tongue, 103. Tongue moist ; skin in a profuse perspira- 
tion ; says that he took last evening a dose of salts and cream of 
tartar, which operated twice this morning. R. — When fever goes 
off, give sulphate of quinia, grs. v, every three hours up to grs. xx. 

Oct. 10th, 12 o'clock M. There was a complete intermission of 
the fever about 2 o'clock this morning. At this time the sulphate 
of quinia was commenced, and he has taken gr. xv. 

' Medical Times and Gazette, May 30, 1857, p. 540. 



292 



OBSEEVATIONS ON 



Amount of urine passed during the last 16 hours . . 6144 grs. 

hourly u u , ^ 321.5 u 

Calculated amount of urine for 24 hours . . . 9216 " 





In 6144 grains of 
urine (16 hours). 


In 9216 grains of 
urine calculated 
for 24 hours. 


In 1000 parts 
of urine. 


Urea 

Uric acid .... 
Fixed saline constituents 


226.980 grs. 

0.600 " 
40.200 " 


340.470 grs. 
0.900 " 
60.100 " 


36.943 
0.097 
6.542 



Sp. gr. of urine 1024 — clear; no deposit; light red color. Ee- 
action decidedly acid. After standing 12 hours no deposit ; after 
standing 36 hours, a very slight light-yellow deposit; after standing 
60 hours the surface was covered with a pellicle, which, under a 
magnifying power of 210 diameters, was found to consist of small 
oval cells, about the size of human blood-corpuscles. There were 
also other elongated elliptical cells, the short diameters of which did 
not differ from those of the globular cells. Many of the elongated 
cells had a vibratory motion. The deposit at the bottom consisted 
of these globular elliptical acicular cells, and a few crystals of 
triple phosphate. That these cells were organized bodies was de- 
monstrated by the action of chemical reagents under the microscope. 
Not a trace of uric acid was found in the pellicle and deposit. 

12 J ddoch P. M. A chill is just coming on. The thermometer 
placed in his hand^ indicated 91.6° F. Simultaneously luith the in- 
crease in the sensations of cold, it commenced to descend, and in fifteen 
minutes stood at 87.5°, 10 J degrees below the normal standard. In 
fifteen minutes his hand lost 4°, and simultaneous with this loss of tem- 
perature in the extremities, the sensation of cold increased. He feels very 
cold, hut does not shake. The extreinities feel cold, whilst the surface of 
the head and trunk feels hot and pungent. When the hull) of the ther- 
mo7neter was simply placed between the skin and flannel shirt, and gently 
pressed against the surface of the chest, it commenced to rise rapidly, and 
in a few moments indicated 103° F., and when placed in the armpit, it 
rose rapidly to 107° F. Pulse 100, not so full as during fever, but 
small, feeble, and threaded. Respirations 26, full and labored. Tem- 
perature of atmosphere, 6S. 6° F.] temp, of hand, S7 .6° ; temp, of axilla^ 
107°. Tongue pointed, but moist, and not much redder than usual. 
Skin dry, ivitli a purplish mottled appearance as if the circulation in the 
capillaries teas retarded. Says that he has dull " wandering pains 
around his loins up to his chest. Comp)lains of great thirst. His sto- 
mach is so irritable that I could not ascertain the temperature under his 



MALARIAL FEVER. 



293 



tongue. I made seven unsuccessful attempts. At every trial the contact 
of the bulb of the thermometer with the base of the tongue excited violent 
retching and vomiting. I applied a sinapism over the region of the 
spinal column^ eighteen inches in lengthy and three inches in breadth^ 
also one over the epigastrium^ and administered stimulants. In half an 
hour after their application^ the mustards and stimulants assisted in 
arousing the capillary circulation in the extremities. His surface does 
not present the mottled appearance ; the heat has^ in a great measure^ 
returned to his extremities; the cold sensations have disappeared^ and he 
'■''feels warm all over^ The temperature of his hand is now 99°, whilst 
the temperature in the axilla is still 107°. In half an hour the tem- 
perature of the extremities has risen 11.5°. The temperature of the 
hand does not correspond fully with that of the trunh^ and reaction is 
not yet fully established. 

Has just passed clear limpid straw-colored urine. Sp. gr. 1003. 
Amount of urine voided, 7021 grs. 





7021 grains of urine 
contained. 


1000 parts of urine 
contained. 


Fixed saline constituents 


Grains. 

39.551 
0.420 
9.800 


5.650 
0.059 
1.395 



Nitrate of urea remarkably silky and white. 

Microscopical Examination. — The urine was placed in a closely 
stoppered bottle, and set aside for sixty hours. At the end of this 
time there was a pellicle over the surface, and a small light-yellow 
deposit. The pellicle consisted entirely of the globular, elliptical, 
and vibrating cells, observed in the former specimen. The deposit 
also consisted of these cells, and a few beautifully formed, pris- 
matic crystals of triple phosphate. This specimen of urine was 
interesting, because it was passed at the close of a chill, and was 
probably excreted by the kidneys during the existence of the cold 
stage. It was much lighter in color than that passed during fever; 
in fact it resembled the urine of hysterical women, in its light color 
and low specific gravity. 

Phenomena during the Hot Stage and Period of Intermission. 

Proposition Y. The higher the temperature of the trunk during the 
cold siage^ and of the extremities and trunk during the subsequent hot 
stage {stage of equalization of the circulation and chemical aciion\ the 



294: 



OBSERVATIONS ON 



milder and shorter will he the attach^ as a general rule^ provided there 
he no complication^ as congestion of the hrain. 

Whenever, as in congestive fever, there is a want of correspond- 
ence between the circulation, respiration and chemical changes, 
the patient is always in danger. A patient with a rapid feeble 
pulse, and rapid thoracic respiration and low temperature (sluggish 
chemical changes), is always in great danger. In cases of malig- 
nant (congestive) malarial fever there is, as far as my observations 
extend, a want of co-ordination between the actions of the circula- 
tory and respiratory systems, and the rapidity and character of the 
chemical changes. The heart attempts to propel the blood; it 
beats rapidly (flutters 140 to 160 times in the minute), but the 
blood does not flow readily through the capillaries, because the 
chemical changes are in a great measure arrested, and in many 
cases perverted. On the other hand, the bounding, full, accelerated 
pulse; the full, heaving, accelerated respiration, and correspond- 
ingly high temperature, are always favorable symptoms, provided 
there be no complication, as obstinate vomiting, or cerebral symp- 
toms. The severity of the fever is hy no means proportional to the 
height of the fever {animal temperature)^ for^ as a general rule^ the 
higher the fever {temperature)^ the more readily does the attach yield to 
treatment^ and the less serious the effects. 

A high temperature, then, in intermittent fever, is a favorable 
symptom. 

Whether the high temperature signifies an effort on the part of 
nature to break up, chemically alter, destroy, and throw off, the 
malarial poison ; or whether the high temperature be significant 
of nothing more than vigorous, vital, nervous, physical, and chemi- 
cal forces; nevertheless the determination of the correlation of the 
respiration, circulation, and temperature, affords the most valuable 
information to the medical practitioner. 

Proposition YI. In malarial fever there is a close relation hetween 
the state of the sJcin^ pulse, respiration, and temperature of the extremi- 
ties and trunk. 

A rapid, full pulse, hurried, full respiration, and dry skin, were 
attended with a corresponding elevation of temperature. If the 
functions of the organs and apparatus be properly performed, a 
full, and rapid, vigorous circulation and respiration, must be at- 
tended by the rapid absorption of oxygen, and exhalation of car- 



MALAKIAL FEVER. 



295 



bonic acid gas, and correspondiDglj rapid chemical changes, and 
development of heat. 

A slow pulse, and respiration, and moist skin, was always accom- 
panied with a reduction of temperature. 

During the intermission of the fever, the slow pulse, and respira- 
tion, and moist, relaxed skin, were attended with a reduction of the 
temperature, in many cases, below the standard of health. 

The questions immediately arise: Is the intermission of the fever 
due to the restoration of the functions of the sudoriparous glands, 
which collectively expose a surface of tubing 1,570,000 inches, or 
nearly 28 miles in length ? Is the morbific agent or agents, which 
have disturbed the chemical actions and correlation of the forces, 
eliminated by these glands? 

If the intermission is due to the restoration of the functions of 
the sudoriparous glands, what excited them to action? 

Is the phenomena connected with the nervous system alone, or 
with chemical and physical changes of the morbific agents, and of 
the blood, and secretions, and excretions? 

If the reduction of temperature be. not dependent upon the re- 
storation of the functions of the sudoriparous glands, what retarded 
the chemical actions by which the physical forces are generated? 

If the chemical actions developing an unusual amount of heat 
were excited by the introduction of foreign elements, may not the 
foreign elements themselves have entered into these chemical ac- 
tions, and been so altered that they have been for a time rendered 
inert? 

That a special end is accomplished in malarial fever by an eleva- 
tion of temperature, is proved by the fact that the cases which 
manifest the highest temperatures, are, as a general rule, attended 
with little or no danger ; whilst in those cases, as congestive fever, 
where there is a depression of temperature, the danger is always 
imminent. 

It is true that the sudoriparous glands have much to do with the 
regulation of the temperature, for the water which they eliminate 
from the blood during its evaporation, abstracts one thousand de- 
grees of heat from the surface of the body and the surrounding 
atmosphere. The heat is expended in the mechanical action of 
keeping asunder the particles of water, and is hence insensible to 
the thermometer. The experiments of Dr. Southwood Smith,^ at 



> Philosopliy of Health, vol. ii. pp. 391-396. 



296 



OBSERVATIONS ON 



the Phoenix Gas "Works, and of MM. Berger, Delaroche/ Fordyce, 
Blagden,^ and others,^ have shown that when animals and man were 
subjected to great external degrees of heat, the temperature of the 
body was regulated by the evaporation from the surface of the skin 
and lungs. When the air was dry, individuals were able to endure, 
for a considerable length of time, a temperature of from 250 to 350 
degrees, without injurious effects, and without any great elevation 
of temperature. The loss of water from the surface of the body 
was correspondingly great, and by its evaporation maintained the 
temperature of the interior at the normal standard. If, however, 
this evaporation be interfered with, by saturating the air with 
aqueous vapor, the temperature rose rapidly, and the individuals 
died in a short time. 

The determination of the fact that the sudoriparous glands can, 
to a certain extent, regulate the temperature of the surface, does 
not by any means prove that the remission or intermission of ma- 
larial fever is due to the restoration of the function of these glands. 
In congestive fever, when these glands are active, and the whole 
surface is bathed in perspiration, the malarial poison is far more 
active than in remittent and intermittent fevers, attended with a 
rapid, bounding pulse, and rapid, full respiration, and high tem- 
perature, and hot, dry skin. 

J Experiences sur les Effets qu'une forte Chaleur produit sur I'Economie, Paris, 
1805 ; and Journal de Physique, tomes Ixxi. et Ixxiii. 
2 Pliilosoptiical Transactions, 1775. 

^ Magendie's Experiments upon the Influence of Hot Air on Animal Life ;" Am. 
Journ. Med. Sciences, Jan., 1845, p. 183. M. Constantine James, "On the Effects 
of the Hot Moist Air of the Baths or Stoves of Nero, at Pozzuoli ;" Grazette Medicale, 
27th Avril, 1844. W. F. Edwards, " On Animal Heat ;" Cjclopsedia of Anatomy and 
Physiology, vol. ii. pp. 649-684. John Davy, "On Animal Temperature," Phil. 
Trans., 1814; Edinburgh Philosophical Journal, Jan., 1826; see also Researches, 
Physiological and Anatomical, by John Davy, London, 1839, vol. i. pp. 141-248. 
Experiments of Tillet and Duhamel, " Experiments on the Servants of a Baker, at 
Rochefoucault, in Angoumois ;" Mem. Acad. Scien., pour 1764, p. 186 et seq. 
Experiments of Dobson at Liverpool ; Phil. Trans, for 1775, p. 463 et seq. " Obser- 
vations on the Effects of High Temperatures," by Bell, of Manchester ; Manchester 
Memoirs, vol. i. p. 1 et seq. Currie " On the Application of Water at Different 
Temperatures ;" Phil. Trans, for 1792, p. 199 et seq. Experiments of Delaroche, 
Journ. Phys., t. Ixiii. p. 207. Nicholson's Journ., vol. xvii. p. 142, 215. Journ. 
Phys., t. Ixxi. p. 289, and t. Ixxvii. p. 1. Lavoisier on Transpiration, Mem. Acad, 
pour 1790. John Reid on Respiration, Cyclopsed. of Anatomy and Physiology, 
vol. iv. pp. 325-368. 



MALARIAL FEVER. 



297 



Appearances of the Tongue in Intermittent Fever. 

In almost every case the papillae of the tongue were enlarged, 
and of a bright, red color. In the mildest cases the tongue was 
only slightly coated with white and light yellow fur, and the tip 
and edges were redder than normal. In the severest cases the tip 
and edges of the tongue assumed a bright- red color, and the tongue 
was much dryer than in the milder cases, and the reaction of the 
saliva more intensely acid. The fur of the tongue in many cases 
was thick, and of a brownish-yellow color. The reaction of the 
saliva was always acid during the active stages, and the intensity 
of the acid seemed to correspond, in a measure, to the severity of 
the disease. 

Characters of the Urine in Intermittent Fever. 

In the mildest cases the characters of the urine did not differ 
very essentially from those of health. 

As a general rule the amount of urine excreted during the active 
stages, and during the earliest period of intermission, when the 
temperature of the trunk and extremities sinks below the normal 
standard, was less than that of health. During convalescence, espe- 
cially under the action of depurants, the amount of urine excreted 
was greatly increased. 

These statements cannot be applied rigidly to all cases, for the 
urine is affected by so many varied external and internal condi- 
tions, that the amount excreted exhibits great fluctuations, even in 
health. No two observers agree with reference to the amount ex- 
creted in definite periods. 

Thus, Lecanu, from the examinations of the urine of sixteen 
individuals, living upon mixed food, estimated that the amount of 
urine discharged in twenty-four hours ranged from 8085 grains to 
84,973 grains. 

Becquerel found that the mean daily quantity passed by four 
men was 19,511 grains, and that by four women was 21,130 grains. 
Lehmann, from experiments instituted upon himself, estimated the 
quantity discharged daily at from 13,829 grains to 22,299 grains. 

According to the valuable experiments of Dr. William A. Ham- 
mond, instituted upon himself, the amount of urine excreted under 
a mixed diet ranged from 19,684 grains to 22,756 grains, with a 
20 



298 



OBSERVATIOXS ON 



mean of 20,898 grains; under a diet of albunien, from 12,325 to 
21,592, with a mean of 17,738; under a diet of starch, from 14,339 
to 23,352, with a mean of 18,127 grains; and under a diet of gum, 
from 20,516 to 23,721 grains, with a mean of 21,538 grains. 

The only accurate method of determining whether or not the 
urine be increased or diminished is to refer it to the standard of 
health in the individual examined. In hospital practice this is in 
the majority of cases impossible, and we are compelled to be con- 
tent with approximate results. 

The density of the urine was slightly increased in the majority of 
cases during the active stages, and in others it remained at the 
standard of health, and in others, again, it varied within wide 
limits. 

The cohr of the urine varied from deep yellow and the normal 
yellow color to light red. During the active stages deep orange 
was the most common color. 

The intensity of the color was greatest during the active stages, 
and diminished during convalescence. 

Daring the active stages of intermittent fever the urine always 
contains more FREE ACID than in health. It will retain the acid re- 
action for several days, even in the heat of summer. 

When the fever intermits, and the skin is soft and relaxed, and 
the patient is convalescent, the urine then excreted rapidly under- 
goes decomposition, and in a few hours the reaction changes from 
acid to alkaline. I believe this to be one of the most certain signs 
of convalescence in malarial fever. The acidity of the urine in 
malarial fever is in proportion to the severity of the attack ; it is 
more intense in remittent that in intermittent fever, and still more 
intense in congestive fever than in intermittent and remittent fever. 

The urea icas increased during the active stages above the stand- 
asrd of starvation. During the active stages the patients took little 
or no nourishment, and the urine excreted during these periods 
should be compared with that excreted during starvation and re- 
pose, and not with that of health. Unfortunately the standard of 
the urine during starvation varies with each individual, and as it 
is impossible to establish a standard previous to the attack in the 
great majority of hospital patients, we can only establish approxi- 
mate results. 

In the majority of the cases the URIC acid ivas diminished^ both 
with and without the action of the sulphate of quinia, during the 
active stages, when the pulse was full and rapid, and the respira- 



MALAEIAL FEVER. 



299 



tion full and accelerated, and the temperature elevated. In almost 
every case, as the fever declined, the uric acid increased above the 
standard of health, both with and without the action of the sul- 
phate of quinia. 

From the microscopical examination of several hundred speci- 
mens of urine excreted during the different forms of malarial fever, 
I found it, as a general rule, to be true that, in the mode of treatment 
which I adopted, the uric acid appears in much larger quantities in 
the urine of convalescence than in that excreted during fever, even 
when the sulphate of quinia had been withheld, or sparingly ad- 
ministered. 

The majority of specimens of urine excreted during fever, which 
were set aside and examined under the microscope, at successive 
intervals, gave no deposits of the crystals or salts of uric acid, 
whilst specimens of the urine of convalescence very soon gave 
evidence of the presence of uric acid, by letting fall deposits of 
urate of soda and ammonia. 

As far as my observations extend, it may be stated, as a general 
rule, that the phosphates are more ahundoM in the stage of conva- 
lescence than during the active stages. 

The deposits so common during convalescence consist chiefly of 
urates of soda and ammonia, and the phosphates most generally 
in the form of the triple phosphate. 

The chief reason why the deposit of the phosphates is more fre- 
quent in the intermission than in the active stages is because the 
urine in the active stage of convalescence is far less acid, and far 
more readily decomposed and rendered alkaline by the ammonia 
•resulting from the decomposition of the urea, than the urine of 
fever. 

These facts explain the nature of the so-called critical discharges 
of malarial fever. The urine excreted during fever is generally 
deficient in uric acid and the earthy salts, whilst its acidity and 
power of resisting decomposition is greatly increased, and it will 
remain for a great length of time without undergoing decomposi- 
tion. The urine of convalescence, on the other hand, is rich in 
uric acid and the earthy and alkaline salts, and readily undergoes 
decomposition. •The deposit of the urates of soda and ammonia, 
and the precipitation of the triple phosphate by the ammonia gene- 
rated during decomposition of the urea, form the so-called critical 
discharges. As a general rule, the urine excreted during the hot 
stage of intermittent fever is poorer in uric acid than the urine of 



300 



OBSEEYATIOXS 0:T 



remittent fever; and I have known cases in which, daring fever, 
the uric acid disappeared almost entirely. In several cases of con- 
gestive fever the urine contained only traces of uric acid, and in 
one case, which terminated fatally, the disappearance of the uric 
acid was attended with the disappearance of the urea. Dr. Eanke^ 
states, in his article upon the physiological action of sulphate of 
quinia, that, according to all observers, there is in ague an increase 
of uric acid. My observations do not correspond with this asser- 
tion, if it is intended to apply to the active stages of intermittent, 
remittent, and congestive fevers. The fact that uric acid increases 
during convalescence from malarial fever demonstrates conclusively 
that the diminution of the amount of uric acid by sulphate of 
quinia is an attending circumstance, and not necessarily one of the 
beneficial remedial modes of the action of this medicine. 

As a general rule, the extractive axd coloring matters are 
less ahundant during the active stage of intermittent fever than 
during the first period of the intermission. They are either not 
formed in such abundance, or if formed, are partially consumed 
during the active chemical changes of fever. 

The nitrate of urea formed from the urine excreted during the 
active stages of intermittent fever is silvery white, whilst the 
nitrate of urea formed from the urine excreted during the inter- 
mission is dark, discolored, and the crystals are not so well formed. 
The former kind of urine, when evaporated and concentrated, gene- 
rally has a yellowish or brownish color, whilst the concentrated 
urine of the intermission assumes the color of a very strong decoc- 
tion of over-parched coffee. The depressed state of the forces con- 
sequent upon the continued action of the malarial poison is, as far- 
as my observations extend, attended by a marked diminution of 
the solid constituents of the urine. 

These propositions and statements will be illustrated by the fol- 
lowing cases : — 

• Medical Times and Gazette, Maj 30, 1858, p. 537. 



MALAEIAL FEVER. 



301 



Color and 

MiCROSCOriCAL 

Examination of 
Urine. 


Light orange ; af- 
ter 50 hours, no 
deposit of nrates 
or phosphates. 

Normal color ; no 
deposit. 

A shade higher 
than normal. 

Deposit of nrates 
and phosphates. 

Light yellow; 
phosphates and 
urates precipi- 
tated. 

Color normal; de- 
posit. 

Color normal; de- 
posit. 


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1.3376 
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Grs. 

30952 

15300 
30731 


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Grs. 

1.0035 

2.0000 
9.3000 
8.1000 

15.000 


•A}iavjl§ ogpads 


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1009.5 

1020.0 
1011.0 
1020.0 

1010.0 

1018.0 
1015.0 


•sjnojj 
HI paja.ioxa anijj^ 


CO . CO O -tl -H -H 


Grs. 

23220 

5100 
19209 
15810 

18180 

20520 
30150 


•jC^.tuoii 
pa^aioxa auufi 


Grs. 
1290 

1 i'ho 

1011 
658 

757 

855 
1268 


•s.TnoTx fz ni 
pa^ajoxa pio'B ou^l 


Grs. 

3.6()35 
9.3000 
8.1000 

15.000 


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Grs. 

28320 
24309 
15810 

18180 

20520 
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•anSuoj 
japnn ain;'Bjaduiaj^ 


106.0° 

99.5 

10.).5 
105.0 

98.5 

102.0 

98.5 

99.5 
99.3 


•pn'Bq 
JO a.inj'Biadraax 


103.33° 

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91.00 
103.50 

95.00 

100.50 

96.00 

96.00 
96.00 


•ajatfdsonij'B 
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79.0° 
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74.0 

74.0 

72.5 
70.0 


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c<i ^^^ c(Meo(M o Oi-i 

CO <M COC0<MC0 C<1 (MfM 


•asinj 


O O COGOyS'* C-l OCX 

CI oot-co CO coco 


State op 
Skin. 


Hot, dry 

Cool, relaxed 

Chill 
Hot, dry 

Cool, moist 

Warm and 
moist 

Cool and 
moist 

Normal 
Normal 


Medicine. 


Calomel gr. xij, sulp. 
qui. gr. vij, castor oil 
in 4 hrs., sulph. qui. 
gr. XXV. 

Spirit of mindererus. 
Sulph. quinia gr. xx. 

Sulph. quinia gr. v. 

Calomel gr. vj, sulph. 
qui. gr. vj, castor oil 
in 4 hrs., sulph. qui. 
gr. XV. 

Snakeroot tea and sul- 
phate of quinia. 

Quassia and soda. 
Quassia and soda. 


Hour 

OF DAY. 


7 P. M. 
IP. M. 

5 P. M. 

8 P. M 

11 A. M. 
11 A. M, 

11 A. M. 

11 A. M. 
11 A. M. 


Date. 


o: o oorHCl CO -.^iio 

CX CO CO 



OBSERYATIONS ON 



02 



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Color and Reaction 
OF Urine. 


I^ight orange color. 

Reaction strongly acid in 

70 hours. 
Reaction alkaline in 16 

hours ; heavy deposit. 


•anuTi JO 

£%iAViS ogioodg 


1022 

1030 

1026 
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Grs. 

313.3 

363.3 
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Grs. 

8210 

8721 
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106.00° 

99.00 

99.20 

99 50 
99.50 


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105.75° 

94.50 

94.75 

98.20 
98.20 


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CO C<f CO CO 


•noi^'BJtdsoa 






<N O O »0 O 


State of Tongue, 


Red, dry, rough 

Moist, soft, and clean 

Normal 

Normal 
Normal 


- 

State of Skin. 


Hot, dry 

Moist, soft, and relaxed 

Normal 

Normal 
Normal 


Medicine. 


Cal. gr. viij, castor oil in 
4 hours, cit. potassa mix- 
ture, sulphate of quinia, 
gr. XV. 

Sulphate of quinia, gr. v. 

Snakeroot tea, quassia, 
and soda. 
Quassia and soda. 
Quassia and soda. 


o fl 

o 


S S S 

net Ha (M 


Date. 


»0 O QO O 
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O - - - - 



MALAEIAL FEVER. 



303 



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Grs. 
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1.00 
5.01 
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•sinoq 


I Grs. 
310.0 

397.7 
251 4 
162.9 


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Grs. 

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21859 


pa;a.Taxa anufi 


Grs. 
321 

760 

590 
1680 
942 

680 


•s^naujps 
-G03 ani[i3s paxij 


Grs. 

40.2 
9.8 

28.5 

40.5 

29.7 
115.2 


•ppu aufi 


Grs. 

0.600 
0 420 

0.250 

3.150 

2.025 
9.600 


•■Gain 


Grs. 
•• 

226.0 
39.0 

99.4 

1.57.0 

101.8 
488.0 


•i^iAUiS ogpadg 


1024 
1003 

loio 

1016 
1008 
1012 
1020 


•sjnojj 
HI pajaioxa anun 


CD • O 05 ^ -H 
r-i • i-H r-H (M 


Grs. 

6144 
7021 

5075 

9144 
1.5120 
13662 
16320 


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Grs. 

78.5 
115.2 


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pa^ajoxa ppu auji 


Grs. 

1.27 
9.*60 


ut pa^aioxa uajfi 


05 OO 

2 : • • -o • • -o) 
o • • • 


•sanoq; 
HI pajaaoxa 
ani.iti JO (jnnoniy 


Grs. 

18290 

28782 
16320 


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japnn aan^y-iaduiajj 


o 

CO . I>. !>. . . . O . 
O . O O . . . 05 . 


•pu«i[ 
JO ajti^^.taduiaj^ 


o >o CO o 
c<i ! ai oi * ' CO I 
o oo '^•2 


'ajandsoui^B 
JO 8JTi;«jaduiax 


o 

o . o q q . , q . 

c<i ^00 c; . • CO • 

o o o 


•noi^'Biidsaa; 


. CO CD • C-1 O CD CD 
■ (M <M • (M m rH rH 




CO . O O • CO -f CO ^< 

Ci • o o • c« CO CD <r> 


State of 
Skin. 


Warm and 
moist 

Cliili"' 

Hot 

Cool, moist 
Cool, moist 
Normal 
Normal 


Medicine. 


Sulph. of qui. 
gr. XX, 

Spirit of min- 
dererus and 
sinapisms 

Sulpli. of qui. 
gr. XX. 

Suakeroot tea 
Quassia & soda 


Hour 

OF DAY. 


8 P. M. 

12 M. 
i P. M. 

1 P. M. 
7 P. M. 

10 P. M. 

11 A. M. 
10 A. M. 


Date 


Oi oo CO 1-1 (M CO -H 

O 



804: OBSERVATIONS OK 



«^ 2 g 
bo 

H M 



1-4 o ^ 

•^^^ ^ 

.BP ° g S 
^ CM 

.2 « 

"55 13 . 

® S to 

-111 
o ^7 o O 

o q i . 
^ '^X r-^ ^ <a 
^ ^ S ^- ^ 

bp O c3 g 

w . 

^ ^ S 



c 

g g O -3 ^ 
C ^ o o 

s *J "-^ 

rH =3 

CD O O _H 



C 



on 

n 
O 



Reaction, Cot.ok, &c. 
OF Ukine. 


Clear orange color ; still acid, 
with no deposit after 70 hrs. 

Reaction changed from acid to 
alkaline in 36 hours, and de- 
posit of triple phosphate and 
urate of soda thrown down. 

Reddish-orange color ; reac- 
tion acid at end of 50 hours, 
and no deposit. 

Straw-colored. 

Normal. 


•sjq f j; .loj s^nenms 
-noo a-nHBs paxg jo 
:)xiiioniB pa^uinoin^) 


Grs. 
209.5 

7-1.3 
73.6 


•sjnoq 
joj pian OTJti JO 
ianotttB pe^'Binoi'BQ 


Grs. 
9.50 

5.99 
4.40 


•sjq f-g joj 'Bojn JO 
^nnooiB paj'Binox'BQ 


Grs. 
534.0 

452.7 


•sjq f ^ joj Quixn jo 
;TiTioni'B pa:)^!™!^^ 


a: , , C5 

^ 01 ao 


-Tioo emi^s paxij 


Grs. 
87.30 

21.70 
46.00 




O CO r-' e<i 




Grs. 
222.5 

132.0 


•sanoH 

TXT P8J8.IDX9 

enim jo :junoraY 




Grs. 
9198 

3580 

5100 
5120 


•am.in 
JO jJjta'BjS ogioadg 


1022 
1027 

1023 
1020 


•uoT^-BJidsajj 


CO O CO • 
(M (M rH . 


•esinj 


-H • 

1> CD • 


State of Skin and Tongue, 


Skin hot, but moist; fever con- 
tinues unabated. 

Skin cool and moist; papilla) 
of tongue red and enlarged, 
tongue .soft, moist, and slight- 
ly coated with white fur. 

Skin cool and moist; tongue 
clean. 

Skin soft and normal. 
Normal. 


Medicine. 


Sulph. of quinia, 
gr. X. 

Sulph. of quinia, 
gr. X. 

Quassia & soda 

Quassia & soda 
Quassia & soda 


2 < 

c ^ 
o 


Ph' < ^< 

rH i-i CO r-l 


Date. 


O r-l (N (M lO 

C 



MALAEIAL FEVER. 



805 



•SJTIOH 



Quim JO ^(Uiy 



-iTip pa^a.toxa 
s;uan;i}stioo 
aaix'Bs paxi^i 



•sjq^g Suutip 
pa^aaoxa sja; 
-■^v,m gnuojoo 
pu'B aAflo'Biixa; 



•sjnoq fz 
Snunp pa^ajD 
-xa pio^ oufi 



•s.Tqf^SnuTip 
pa:jajoxa 'ea.ixi 



•sjtioq f s Sni 
-.iTip pa^ajoxa 
sja^j'Bni pnos 



•S.ITI f s Sni-inp 

pa^aioxa aa^-B,^ 



pa?a.ioxa 



•sinoq Sui 
-jtip pa^ajoxa 
eniJti JO l,rav 



•anSno; .lapnn 
aitn'Bjadniajj 



•pn'Bq 
JO aitH'Bjadniaj, 



•ajaqdsoni:('B 
JO aiTH'B.iadniaj, 



•Tioi^ujidsaa; 



CO (M_ O "O 
(2 • • • 05 CD CD to 

• CO o Ir^ 

^...OrHCOt^ 

• • . -i^ CD CO CO 

oooooooooo 

OO C<| C<1 O O <N O i-( 
OOOOOOOOOO 



r-l i-H • CO 



c^-fr^coiot^moocoGO 

•»0(M!MC0C0OO-t<OC« 
"OtNr-li-li-lT-lr-fi-lrHO 

(N(Mcooaco>o>Oi>^-* 



OOOOOOOOO 
-HCD-HCDOOO(M(M 
; (M lO O i-H -+ CO O 05 r-l 

t>; id lo" »o CO CO CO o 



. i-H !M O CD CD O 

. CD C3 ift 'O (M O 

CO CO CO CO i-H r-l cq 



-tlCOt^OOlOOCOr-ICDin 
CD <M CO CD IM rH CO -f O 'O 
t^COCOrllrJlOTjHCOt^O 



looooiO'^'+'inio 

^ O »0 >0 Ol CO CO 

■ — -1 (M r-l 05 CO 



' CO IM (M (N (M (M ( 



O 'O rH O (M r 



OOOitSiOOOOOilMOcO 



iioooiooooocoo 



O00505a^0i0i050io^0i 



OOOOOOOOOiCO 
.OOOOOOOOOt-O 

' o c<i >d co" »d 05 o' im" go co' 
ooaot~t^lr^ODt^oooot^ao 



•astnj 



laooooococDoooo-rfit^o 

iOt^OOt^I>.COCDt>.CDCO 



ii; <i ^' ^ ^ fi; << ^ <i pl; 

r-ICOOt^OlCDOCO cTt^ r-l rH 



I Ol O O rH r-l (M CO ■ 



•jfptioq 
pa^aaaxa 
atiTjn JO i^my 



•anuti JO 
s^j-Bd oboT ni 
sjnarnT^suoD 
anii'Bs paxi^i 



•auun JO s^.T'Ed 
OOOT til sia^ 
-l^ni Snijoioo 
pnu aATjo^.nxa 



•OTrian jo swnd 
0001 ni piOB OTJ£i 



•auun JO s^i'Bd 
0001 HI 



•attuTi JO 
siJ^d obol HI 
sja;;'Bni pnog 



•anuti JO su'Bd 

odoi "I J^im 



•siq -loj 
s;uan;i;snoo 
ann'BS paxg jo 



•sjq fz JOj sja; 
-:}'Bni§njoopn'B 
aAipT?.nxa JO 



•sjiioq 

JtOj pp'B OlJtl JO 



•sjnoq 

fZ Jioj 'Ba.in JO 
l^mv pa^'Bxnox'BQ 



•sjq f 2 JOJ sja; 

-^'BUI pnos JO 



•sjnoq 
fZ JOJ jajBM JO 



•sjnoq 
fZ Jtoj attiati JO 
^jXn'B pa^^inox'BO 



,COCOO(MCOCOCDCO-tlO< 
O0COO0t>COCOCO'rHC0-tl< 

sqioco'ot-'^io-^ioiMi 



O GO o o 

' CO cq CO >q 

' r4 r-i (m" o' CO* 

(M <N <M cq (M 



>ra "O >-o 00 CO CD o Oi O 
.oascoor-cqoioco-^icq 

.C^COlMt^Ot^rH-^OrHCO 

OOOOo'ooOOr-ir-J 



OOOOOOOOO 

,0iO500OC5TtlC0C0rt< 
' rH Ci 00 lO go' C<i <N 03 
COeOCqrlMrHrHrHrH 



Oi »0 O CO o 



CO O t- O O O r 

CO -ti o CO cq o ( 

' CO "O "O O CO »o t 



CO CD O 



1>01000>OOCO 



ei Tl< CO CO CO rl (M 



CDCOGOI>.COOCO»0 



•s^nati'jtjstioo 
eutx'Bs paxt^i ^ 



•sjaj 

-'ivm. gnijoxoa 
pu'B aAipBJjxa 



"Baifi 



o fi 
o 



I O O O M O 



CDCO-^iTfrt^OOO 

; r-i oi CO t-" CO' co" CO ! 
00 r-l CO rH CD CD CO 
cq rH cq rH rH 



(i; ph' <j ph' <i ph' -4 dl ;^^Ph' <ti ph' s <i 

rHcoot-oicooco o ^ 



lOlOSOOr-lrHCqcO-* 



806 



OBSEKVATIONS ON 



^ O tD 

S oo o 



o c^ 

"o =^ 
§ 05 

^ . 15 

s ^§ 

^ rl ^ 

CO O 

>^ hp 

Pi Ph Sh 

... o; |S 

ft CO m 

c3 ts o) 
d o .3 
•§ 

rd ^ P 



o a> 
o ^ '^-i 



^ ^ ^ 
o o 

3 c3 e« 



1^ cS o 



3? ^ 

S © 0? 



•saiioq joj 
-i^suoo euipes p3xij[ 


aj , . _ CO lO 
. . . -H CD 


•sjtioq fz JOj 
paj'Binoi'BD piDB OU£l 


Grs. 
0.400 
2.275 
13.840 

9.520 
11.2.50 


•sjnoq fz 

joj pej^xnoi'UD 'Bean 


Grs. 

2.52.2 
136.1 

517.3 
319.2 


JO '\^mv psjuitioi'BO 


Grs. 
408 G 
6641 
6640 
7530 

13899 
15330 


-psnoo anii'BS paxi^ 


aj . . . . . . .<=> '"5 

• . .00 d 


•piO'B OIJ£l 


Grs. 
0.400 
2.275 
13.840 

5.950 
11.250 




Grs. 

2.52.2 
136.1 

3*12.1 

319.2 


•sjnoji 

TII P9J9.TDX8 

9uuti JO ^unoniv 


^ • " "2 c5 


Grs. 
4086 
6641 
6610 
7530 

8687 
15330 


•anun 

JO A^iAViS o^padg 


1021.5- 
1021.7 
1023.0 

10*2*2.0 

1022.0 


•9tiSao:j 
japun aiTH-Bjaduiej, 


99! 0° 
98.0 

101.5 

102.5 
98.5 


•pn'Eii 

JO 9JtH'BJ[9dni9J, 


0 

lO 0 00 >o 
I ; CO cd' I CO 1— - '. 

0 01 CO 0 C5 


'9.T9qdsorai'B 
JO oan;^a9din9x 


88.'o= 
89.5 

75.0 

70.0 
70.0 


•uop'BJTdsaa: 




•9SITIJ 


.... . cq CO . 

.... . OS 0: . 


Skin, Medtcine, Color of 
Urine, &c. 


Apyrexia ; skin cool. 
Apyrexia ; skin cool. 
Apyrexia ; skin cool. 
Convalescent. 

Continued to improve and was dis- 
cliarged September 23d. 

Has returned ; has had chill every day 
since the 5th inst., at 11 o'clock A. 
M. ; calomel, gr. xij, sulphate of 
quinia, gr. xxv. 

The chill has returned; pulse very 
feeble, with difficulty counted ; re- 
spiration irregular ; lips and fingers 
blue. 

Hot stage ; pulse much fuller. 

Febrile excitement has almost entire- 
ly subsided ; sulph. of quinia, gr. 
xxv ; urine high colored, like new 
Madeira wine. 

Pulse, skin, and tongue normal ; con- 
valescent. 


Hour 

OF DAY. 


gggs pi; pin' fi;<i < 

(M N (M (M -W -in -lOrH 1-1 
r-1 r-1 rl rH CO CO CD rH r-4 


H 
Irt 
■< 
(=1 


■o.- - - "S - - - 



MALARIAL FEVER. 



807 



Character of Urine. 


Amount of urine excreted during fever in 
six hours, 7035 grains. 

Urine excreted during fever, clear and 

light colored. 
Amount of urine passed in seven hours of 

the intermission, 6089 grains ; uric acid 

0.48 grains. 
High color. 

Heavy deposit of prismatic crystals of 
triple phosphate. 




Grs. 

a trace 
1.20 

5.60 


•sitioii fz 
Snunp pa:j9jax8 

9UIJtl JO IJHIIOUIY 


Grs. 

3000 
2000 

14120 
14126 


•eniin jo 
jCjiAnag ogpadg 


>o as 

O i-H r- o 

o o o o 

r-l r-l rH rH 


•eTiStio? J9p 
-un ejti^'Baodutojj 


O 

<D -CO rH 00 
O 'OS O 05 


•panq 
JO ajtunjodraajj 


o 

CD ■ • O to 
O • • O 05 


•oioqdsora:)^ 
JO 8jn:j'BJ8draajj 


O 

0 • O O 

01 -OS COM 


•uoi^niTdsaa 


"In 

O CD • M 

(MM • (N CM rH 




O O o «D <M 
CO O O t- 00 


6 

s 

t) 
o 

o 
Ph 


Intermission. Skin cool and moist; tongue 
slightly furred. 

Fever has returned; complains of great: 
thirst, and pain in head ; tongue coated 
in the middle with yellow fur, red at 
tip and sides ; skin dry. 

Skin softer, but still very hot ; fever con- 
tinues. 

Skin cool ; tongue covered with yellowish 
fur. 

Slight febrile excitement. 


Hour 

OF DAT. 


S ^ 2 ^ : : 

Cq (M 00 <^ 


Date. 


!>• OO CO 05 O i-H 
rH rH rH rH (M cq 



308 



OBSEEVATIONS ON 



c3 

o — c 

O to 

.St 



If 



CM rj 



02 ^ 
O 

02 



o 

02 > 



fc£ 

^ f-" 

O ® (D 
^ 02 ,U 

00 tB 

T-i tea 
® .5 "a 

§ 

a 

§f 
a £ § 



^ Ph O 
< ^ a> 



Deposits in 

UliiNE. 


Reaction decid- 
edly acid after 
60 hours, aud 
no deposit. 

No deposit. 

No deposit. 

No deposit. 

Reaction still 
very acid ; no 
deposit. 

Reaction of 
urino changed 
from acid to 
alkaline in 12 
hours, and let 
fall a heavy, 
shin'g deposit 
of triple phos- 
pliato; the 
crystals were 
numerous and 
beautiful. 


•onun JO JopQ 


Deep 
orange 
red 

Deep 
orange 
inclin- 
ing to 
red 
Deep 
orange 
rod 
Deep 
orange 
red 
Light 
orange 

Light 
orange 


•siq .loj sjnen; 
-psnoD annus paxg 
_jo i.rat; pejuinoiuo 

"saq f^; joj sjanKtu 
Snijoo pnB 9A,.Tjxa 

JO j,ni'B paimuoiuQ 


G rs. 
68.70 

72.77 


O r-H 

£ • o • I I ■ 

• CO • • • ' CO 


•sjqfjjjoj ppu oun 
JO i^m.'B p9]Bxn3i['B3 


Grs. 

trace 

1 

16.35 


•siq fz JOJ 'B9Jn 


Grs. 

.305.5 

200.01 


•sjq fz JOJ ja^UAs. 
JO ijOfB pajBino^-BQ 


C5 o 
X . 'fl . . . . uo 
. 1—1 . . . . o 


•sjq ^-j; .loj 9ni.in 
JO i^m-e pa;Bi;no^'B3 


Grs. 

110689 
18414 

11446 
14029 
12252 

14071 


-HOD aun^s poxij 


Grs. 
45.8 

60.4 


-00 puu aATJOBJJXa 


Grs. 
110.3 

20-4.2 


•piOU OTJJ^ 


Grs. 

trace 

8.624 




Grs. 
203.70 

161.04 




Grs. 

6766.0 

11291.3 


'sjnoH 


CD 00 O O O 


ni pessud 
OTiTjn JO ;nnoniY 


Grs. 

7126 
6138 

7154 
4092 
10210 

11726 


•anun 

JO jfiTA'BjS o^podg 


1018.0 
1022.0 

1020.0 
1022.0 
1021.0 

1019.7 


japrni om^Bjadinax 


103.0° 

99.0 
103.9 

103.0 
102.9 
98.0 


•pnuq 
JO oiniuiodniax 


102..0° 

98.5 
102.5 

102.2 
101.0 
96.0 


•oiondsouii'B JO -caajQ 


o 

o CO (N cq «S «5 

00 OO CO CO CO 00 


•nop-BJTdsoa 1 g J5 N S S ^ : 


•OSITIJ 


O ^ O CO o o 
CO O C5 05 «5 


!5 . 

fa g 

E- S 

CO 


Tongue slightly 
furred ; skin 
warm. 

Skin cool; tongue 
slightly coated 
with white fur. 

Skin hot ; tongue 
slightly furred. 

Tonguo moist ; 
skin hot. 

Tongue slightly 
coated with 
white fur ; skin 
moist and cool. 

Tulso, skin, and 
respiration nor- 
mal ; up and 
walking about 
the hospital 
grounds. 


B 

s 

5 

K 


Cal. gr. 

xij, castor 

oil in 4 
hrs., sulp. 
qui. gr. X. 
Sulp. qui. 
gr. X. 

Sulp. qui. 
gr. XX. 

Quassia & 
soda. 


•^'Bp JO jnoH 


cc ^* ^ fe-< -lo^ ^ S -If _^ S" o 
^ . S CO . i-i . »a . . ^ . 

pu, <5 a, -si 


Date. 


i-i (M (M . CO CO »r; 

p, ^ ^ 
c "* 



MALAKIAL FEVER. 



309 



Deposits in Urine. 


Reaction strongly acid. 
No deposit. 

Do. 
Do. 

Do. 
Do. 
Do. 

Reaction strongly acid ; no 
deposit after 60 hours. 
Do. do. 

Do. do. 

Do. do. 
Do. do. 
Do. do. 

Do. do. 

Heavy deposit of urate of 
soda and triple phosphate. 
Do. do. 


Color op 
Urine. 


A shade 
higher than 
normal. 

Deep orange 

color. 
Reddish 

orange. 

.... 

High color- 
ed. 

Shade of Ma- 
deira wine. 
Do. 

Do. 




Grs. 
2.88 

trace 


•sjiioq 
fZ TIT pajojoxa 
8ni.m JO ^jtay 


Grs. 1 
18144 

•• 

14112 

15290 

35070 
12hrs. 


•onun JO 


1008 

1008 
1016 
1002 

1020 
1020 

1021 
1020 


•anSnoj .lopun 
e.Ttij'BJodinax 


104.0° 
99.0 

102 25 
106.0 

98.5 

106.0 
99.7 

100.0 
102.75 

99.0 
98.0 


•pn'Bq 
JO oaTH-Biodniax 


100.0° 
97.5 

89.0 
105.0 

96.5 

104.0 
98.0 

99.0 
99.0 


•oaaqdsoui^'B 
JO 8in;'BJ9draajj 


90.5° 
91.0 

79.0 
77.6 

76.0 

88.0 
88.0 

86.0 
86.0 

89.0 
85.0 




•osinj: 


(MOO OO 00 • . (M<M(M(Miq5000<M 
i-H CO (MO O • • i-H rH (35 i-H 00 03 C5 


State op Skin and 
Tongue. 


ChiUis just going off. 
Skin cool and moist. 

Lips and hands purple; 
violent chill. 

Skin hot and dry; tongue 
red at tip, but moist and 
soft. 

Skin cool; pulse full and 
soft. 

Skin cool and normal. 
Skin hot ; high fever. 

Face red ; skin hot. 

Tongue red at tip, furred 
and pi)inted. 

Skin cool, moist, and re- 
laxed. 

Skin hot and moist. 
Skin cool and moist. 
Skin warm and soft. 

In profuse perspiration. 


Medicine. 


Sulph. qui. gr. xx. 

Cal. gr. xij, sulph. 
qui. gr. vij . 
Sulp. qui. gr. xxv. 

Comp. blue pill and 
casror oil. 
Sulph. qui. gr. xv. 

Sulph. qui. gr. xv. 


is 

K § 


11 A. M. 
2 P. M. 

2 P. M. 
21 P. M. 

2 P. M. 

2 P. M. 

2 P. M. 

8 P. M. 


Date. 


O0O5 CICO -^VOO (M-t<OOI:^00C00>O 
r-H r-l l-l rH r-l rH rH rH rH ^ r-t 

«3 O < 




- ■ V - ' ^ ■ y- ' 




ai !M O 
iJ, rH rH 


•aSy 


£ m OO 


•9SV0 JO "0^ 1 ft 



13 



r\ T} d Ti^ xy '\T A rvT r\ kt a r\ tvt 
Ui>SJiiK V AilOJN D ON 


Deposits in Ueine. 


Reaction strongly acid. 

Do. do. 
Do. do. 
Do. do. 

Deposit of triple phosphate. 

Heavy deposit of urate of 
soda and triple phosphate. 
Do. do. 

After standing several d' ys, 
a slight deposit of mucus 
and vegetable cells. 

Reaction decidedly acid ; 

no deposit of urates or 

phosphates. 
No deposit. 

Heavy deposit of urate of 
soda and triple phosphate. 


Color of 
Urine. 


Deep orange. 

Deep orange 
red. 

Do. 

High color- 
ed ; deep 
orange. 

Do. 

Do. 

Do. 

Do. 

Deep orange 
red. 

Reddish 
orange. 

Do. 
Do. 
Orange. 
Light 
orange. 


•pp'B OUfl 


Grs. 

8.160 
9.800 

4.600 
36.000 

4.480 

7.400 
2.723 

13.000 


•s.in'T[ 

fZ, HI p9;8.I0X9 

onun JO 5, ray 


Grs. 

9840 
23460 
7161 

9792 
19437 

9180 
22374 

91*80 
10212 


•8ni.TTl JO 

X;iABiS ogpadg 


•• 

1020.0 

1023.0 

1021.0 
1011.0 
1018.0 

1020.2 
1023.0 

1021.0 
1017.0 

1012.0 

1015.0 
1012.3 
1020.0 
1021.0 


•8tL§iro:j lapun 


104.0° 

101.0 

100.0 

104.5 
99.2 
102.0 

104.0 

100.5 
101.5 

100.5 

106.0 

101.0 

104.0 
100.0 
99.0 


•pn'BTi 
JO ajtHTJiadniajj 


103.0° 

103.0 

96.0 

102.0 
98.0 
99.0 

103.0 

98.0 
100.0 

96.8 

105.0 

95.9 

102*0 
99.0 


•9.l9qdS0UH'B 

JO 9.in;E.i9din9jj 


84.0° 

86.0 

84 0 

83.0 
81.0 
80.5 

84.0 

86.0 
84.0 

83.0 

82.0 

81.0 

86.'5 
81.0 
79.0 


•TTr>T1t>TT(T«a\T 1 <^ COrH-HrHGOOO 1— iCO • O OOSCr— 1 


•9sinj 


o o<r>(NcqGoo oo o-tico CO cocovj-« 

03 O 00 05 oo CO CO t> 00 o »o CO ^ 


State of Skin and 
Tongue. 


Tongue red at tip and edges; 

papillaj enlarged, coated] 

with white fur. 
Skin warm and moist; 

tongue the same. 
Skin moist. 

Profuse perspiration. 

Skin moist; tongue point- 
ed, red at tip, and furred. 

Do. do. 

Tongue red at tip and edges, 
pointed, and coated with 
white fur. 

Skin hot and dry ; tongue 
dry ; papillffi enlarged, 
covered with thick yellow 
fur. 

Skin moist and cool. 

Do. do. 
Skin hot and dry. 


Medicine. 


Cal. gr. xii, 
Sulp. qui. gr. xxx. 

Sulph. qui. gr. xx. 
Sulph. qui. gr. xx. 

Sulph. qui, gr. xv, 

Sulph. qui. gr. xv. 
Sulph. qui. gr. xv. 


Hour 
of day. 


8 P. M. 

11 A, M. 

11 A. M. 

12i M. 
11 A. M. 

7 P. M. 

8P, M. 

11 A. M. 
11 A, M. 

12i M. 
2P, M. 

4 P. M. 

6 P. M. 
11 A. M. 

8 P. M. 
11 A. M. 


Date. 


GO 05 O T-l (M (M GO Ol O 1-1 !M OD 03 05 O CO -H 
r-H r-l(M!M(MCqrH i-ICq (MCN i-HrHrH 

ft 32:::::: ft - - -::-:: 

<t © s 

m 


•;qgi9H 


Y- -■''>... -y , . ; V. / 




a; o ■<+i 

J rH rH ,-1 


•eSy 


t -f <^ 
^ <M 


■Qnv.o jo -0^ 1 



MALARIAL FEVER. 



311 



Case (u.) illustrating the diminviion of the constituents of the urine^ 
when the forces have been reduced hy the continued action of the mala- 
rial poison. 

Irish laborer; light-brown hair, brown eyes; has been in America 
seven years, and in Savannah three years; age 22, medium height. 
Has been living and making bricks in a low, miasmatic situation. 
Says that he has suffered with chill and fever for six weeks. Com- 
plexion sallow and anemic; lips, gums, and tongue pale. He is 
exhausted by slight exertions, and complains of great weakness. 

Sept. 16th, 12 J o'clock P.M. Pulse, 88; respirations, 24. Tem- 
perature of atmosphere, 87° F.; temp, of hand, 100.5; temp, under 
tongue, 101.25. 

17th, 111 o'clock P.M. Pulse, 72; respirations, 20. Tempe- 
rature of atmosphere, 86° F.; temp, of hand, 90°; temp, under 
tongue, 98°. Has just awoke from sleep, and is in a profuse perspi- 
ration. 





16,027 grains of urine, 
excreted in 2-1 hours 
(sp. gr. 1001.7), clear 

and limpid, contained 


1000 parts of urine 

contained 


Extractive and coloring matters 
Fixed saline constituents 


Grains. 
15,958.568 
68.432 
42.680 
1.280 
18.776 
5.696 


995.730 
4.270 
2.664 
0.074 
1.171 
0.356 



The reduction of the nervous and physical forces was attended 
by a reduction in the amounts of the solid constituents of the urine. 

— Infusion of Virginia Snakeroot f^xvj ; brandy fovj ; sulph. of 
quinia gr. xv. — Mix. Take a wineglassful five times a day. R. — 
Citrate of iron gr. iv, three times a day. 

17th, 12 M. Pulse, 72 ; respirations, 20. Temperature of at- 
mosphere, 88° F.; temp, of hand, 98.5°; temp, under tongue, 99.5°. 
Amount of urine excreted during the last twenty-four hours under 
the action of the diuretic and tonics, 14,615 grs. ; sp. gr., 1010. 
Urea in 14,615 grs. of urine, 196.910; uric acid in 14,645 grs. 
of urine, 7.975; urea in 1000 parts of urine, 12.445; uric acid in 
1000 parts of urine, 0.544. The infusion of snakeroot, and sul- 
phate of quinia and citrate of iron, have produced an increase of 
the solid constituents of the urine. 



312 



OBSEEVATIONS ON 



Case (v.) illustrating the diminution of the constituents of the urine 
when the forces have been reduced hy the continued action of the malarial 
poison. 

German laborer, age 30 ; height 5 feet 5 inches ; weight, in 
health, 112 pounds; light hair, blue eyes; small, delicate man. 
Has been in the United States three years, and in Savannah three 
months. Has been "keeping store" on the river, near the rice 
mill. AYas taken sick with chill and fever two months ago. Com- 
plexion, anaemic. Complains of great weakness. Lips, gums, and 
tongue pale; tongue coated with white fur. 

10th, 11 o'clock A. M. Says that he had a chill yesterday. 

R. — Sulph. of quinia gr. v, every three hours, up to gr. xv. 

11th, 12 o'clock M. Skin cool; in a profuse perspiration. Pulse 
76, respirations, 19. Temperature of atmosphere, 85° F.; temp, of 
hand, 9i° ; temp, under tongue, 98. Color of urine a shade higher 
than normal. Sp. gr. 1014.5. 





5072 grains of 
urine, excreted 
in 17 hours, 
contained 


7157 grains of 
urine, calculated 
for 24 hours, 
contained 


1000 parts of 
urine contained 




Grains. 


Grains. 




Water 


4886.160 


6895.783 


963.462 


Solid matters .... 


185.340 


261.514 


36.538 


Urea ..... 


65.475 


92.385 


12.907 


Uric acid ..... 


2.750 


3.880 


0.552 


Extractive and coloring matters 


102.485 


144.607 


20.225 


Fixed saline constituents . 


14.631 


20.642 


2.884 



In this case, as in the preceding, we see that the depressed state 
of the forces consequent upon the action of the malarial poison, 
was attended by a marked diminution of the solid constituents of 
the urine. 

12th, 121 o'clock P. M. Pulse, 72 ; respirations, 19. Tempera- 
ture of atmosphere, 84° F. ; temp, of hand, 97.25°; temp, under 
tongue, 99.9°. Sp. gr. of urine, 1011.3. After sixteen hours a 
copious deposit of urate of soda and triple phosphate. 





13,652 grains of urine, 
excreted in 24 hours, 
contained 


1000 parts of urine 
contained 




Grains. 






13,242.437 


970.000 




409.563 


30.000 




209.520 


15.316 




19.710 


1.443 


Extractive and coloring matters 


158.485 


11.676 


Fixed saline constituents 


20.265 


1.567 



MALARIAL FEVER. 



313 



Under the action of the sulphate of quinia, the urea, uric acid, 
extractive and coloring matters, have been increased in amount. 



II. REMITTENT FEYEK 

Proposition YII. The phenomena of the cold stage, preceding the 
hot stage of remittent fever^ are similar to those of the cold stage of inter- 
mittent fever. 

During the cold stage of remittent fever, there is a rapid, feeble 
pulse, full rapid respiration, and hot trunk, and cold extremities. 
The temperature of the extremities is reduced far below that of the 
trunk, and even below the standard of health. The diminution of 
the capillary circulation and reduction of temperature of the extremi- 
ties precede the aberrated nervous and muscular phenomena^ denominated 
chill. The higher the temperature of the trunk, during the cold 
stage, the more rapid will be the equalization of the circulation and 
temperature ; the higher the temperature of the trunk during the 
cold stage, and of the extremities and trunk during the subsequent 
hot stage (stage of equalization of the circulation and chemical 
action), the milder and shorter will be the attack, if judiciously 
treated, provided there be no complication, as congestion of the 
brain, or obstinate vomiting; whenever there is a want of cor- 
respondence between the circulation, respiration, and chemical 
changes, the patient is in danger. 

Proposition Ylll. As far as my observation extends, the most im- 
portant difference betiueen the cold stage of remittent, and that of inter- 
mittent fever, is a difference of degree and not of kind; the 'phenomena 
of the cold stage of remittent fever are more protracted than those of in- 
termittent fever; the sympathetic system is not so rapidly aroused, and 
the circulation in the capillaries of the extremities is not so rapidly re- 
stored in remittent, as in intermittent fever. 

We have before shown that the alterations of the blood are moref 
profound in remittent than in intermittent fever, and that in both 
diseases the alterations in the blood precede the disturbances of the cir- 
culation and respiration and action of the sympathetic nervous system; 
it follows then, as a necessary consequence, that the phenomena of 
the cold stage should be more prolonged in remittent than in 
intermittent fever. 
21 



314 



OBSEKVATIONS ON 



Pkoposition IX. In remittent as in intermittent fever the increase of 
the action of the pulse and respiration is attended hy an elevation of 
temperature^ and the elevation of temperature corresponds more accu- 
rately with the increased actions of the circulatory and respiratory sys- 
tems in intermittent than in remittent fever — that is, the pulse and 
respiration are more accelerated in remittent fever, whilst the temperature 
does not rise higher than that of intermittent fever. 

The explanation of this phenomenon lies in the fact that the 
blood is most altered in remittent fever, and that the chemical 
changes of the capillaries are most disturbed, and probably the 
power of the blood to absorb oxygen, or the force of the circula- 
tion in the capillaries of the lungs, more diminished in remittent 
than in intermittent fever. 

Proposition X. The elevation of the temperature is more persistent 
in remittent than in intermittent fever. 

The alterations of the blood induced by the malarial poison are 
greater, and the effects upon the liver, spleen, sympathetic and cere- 
bro-spinal nervous systems, and upon the heart, are greater than in 
intermittent fever, and hence more vigorous chemical changes are 
needed for the alteration and elimination of these altered offending 
products. 

Proposition XI. The pain upon pressure of the epigastrium is 
more acute, and the vomiting more obstinate, and the cerebral symptoms 
more common and dangerous, in remittent than in intermittent fever. 

Proposition XII. The secretions of the mouth are more completely 
checked, and the tongue is drier, redder, aiid rougher to the feeling, in 
remittent than in intermittent fever. 

In the active stages of remittent fever, the tongue, in many cases, 
especially if it be the first attack of fever, presents, upon those por- 
tions which are clean, a brilliant scarlet color, and dry, glazed sur- 
face ; the papillae are enlarged ; the fur which frequently coats the 
tongue is of a yellowish and brownish-yellow, and sometimes black, 
color, and almost always dry; the tongue, in many cases, feels, when 
the finger is passed over it, as dry and as rough and harsh as the 
surface of a rough board. 

Proposition XIII. The glowing tongue of remittent fever is not an 
index of inflammation. 

It indicates arrest or disturbance of circulation in the capillaries 



MALAEIAL FEVER. 



815 



of tbe superficial parts of the tongue. The secretions of the mucous 
membrane have been checked ; the moisture is evaporated by the 
elevated temperature; the circulation in the superficial capillaries 
is thus retarded, and they become filled with colored blood-corpus- 
cles, which give the bright color to the tongue. 

PROPOSiTioisr XIY. The secretions of the salivary glands and mucous 
membrane of the mouth are 7wt only more dimdnished^ hut they are also 
more 'perverted in remittent than in intermittent fever. The acidity of 
the saliva is greatest in remittent fever. 

The solution of the question, What checked the secretions of the 
salivary glands and mucous membrane of the mouth ? involves the 
consideration of the relations of the malarial poison to the salivary 
glands and mucous membrane of the mouth; involves the con- 
sideration of the relations of the altered products of the blood, 
resulting from the action of the malarial poison, to the salivary 
glands and mucous membrane of the mouth ; involves the con- 
sideration of the relations of the malarial poison and altered ele- 
ments of the blood to that portion of the nervous system which 
presides over the circulation and secretion of the salivary glands 
and mucous membrane of the mouth. 

Proposition XY. The coma, delirium, and severe pain in the head 
so often present in the severe cases of remittent fever, are, as a general 
rule, not indicative of inflammation of the hrain, hut of the stagnation 
of the blood and perversion of the chemical changes in the capillaries of 
the brain, and of the action of the altered blood upon the nervous ele- 
ments, and of the direct action of the malarial poison upon the nervous 
structures. 

The truth of this proposition is established by the effects of 
stimulants and sulphate of quinia in the severest forms of remittent 
fever. 

In numerous cases, I have seen, under the free administration of 
stimulants and sulphate of quinia, the dry, red, glowing, parched, 
hard, rough tongue, become moist, clean, and pale ; the tenderness 
upon pressure of the epigastrium disappear; the circulation and 
respiration abate in force and frequency ; the dry, harsh, hot skin 
become soft, relaxed, cool, and covered with perspiration ; the se- 
verest headache relieved; and the dulness, and even profound coma 
and wild delirium, of the intellectual faculties vanish, and the brain 
restored to the exercise of its normal functions. 



816 



OBSERVATIONS ON 



Proposition XYI. The changes of the urine in remittent fever are 
the same in hind^ hut different in degree from those of intermittent fever. 

As a general rule, the amount of urine excreted during the active 
stages, and during the earliest period of intermission, when the 
temperature of the trunk and extremities sinks below the normal 
standard, is less than that of health ; and during convalescence 
(especially under the action of depurants) the amount of urine ex- 
creted is greatly increased. 

The color of the urine is much deeper in remittent than in inter- 
mittent fever, and varies from deep orange to deep red and reddish 
brown, and in some cases almost black. The intensity of the color 
is greatest during the active stages, and diminishes during conva- 
lescence. 

The acidity of the urine is greater in remittent than in intermittent 
fever. The urine excreted during the active stages is far more 
acid than that of convalescence or of health, and retains its acidity 
and resists decomposition much longer. When the fever intermits 
and the cause of the disease is removed, and the patient is conva- 
lescent, the urine then excreted rapidly undergoes decomposition, 
and in a few hours the reaction changes from acid to alkaline, and 
the phosphates, which, as in intermittent fever, are most abundant 
in the urine of convalescence, are thrown down in the form of 
beautiful silvery, shining crystals, which resemble, when held in 
the sunlight, particles of shining silver. 

The increased temperature and correspondingly increased chemi- 
cal changes of the active stages of remittent fever were attended by 
an increase of the urea, not only above the normal standard, 
during rest and a deprivation of food, but also above the standard 
of active health, and far above the standard of intermittent fever. 
When the temperature falls below the normal standard in the 
earliest stages of convalescence of remittent fever, the urea, as in 
the similar changes in intermittent fever, decreases in amount. 

In the majority of the cases, the uric acid was diminished both 
w^ith and without the action of the sulphate of quinia, during the 
active stages of remittent fever, when the pulse was full and rapid, 
and the respiration full and accelerated, and the temperature ele- 
vated. 

In almost every case of remittent fever, as the fever declined, the 
uric acid increased above the standard of health both with and 
without the action of the sulphate of quinia. 



MALAKIAL FEVER. 



317 



The formation of deposits of the urates of soda and 
AMMONIA AND OF THE TRIPLE PHOSPHATES {critical discharges) in the 
urine of remittent fever is similar in all respects, takes place at 
analogous periods of the disease, and is due to the same causes as 
that of intermittent fever. 

The coloring and extractive matters were diminished during 
the active stages and increased during the subsidence of the fever. 
In several hundred examinations of the urine of the different forms 
of malarial fever, albumen was found in only one case, which was 
complicated with typhoid fever. This fact is important in its 
bearing upon typhoid and yellow fever. 

These propositions will now be supported and illustrated by the 
following cases : — 



318 



OBSERVATIONS ON 



'^i7i o ' 

c <» ^ ^ 

> u 

•j: -r; a 

a o ^ ai ^ 

Q a CU © 

^ iS ? !9 
. 5 g M o 

p ^ > ci 

Sh Q> ^ O « 

O) pq ^ 

^- - g ^ :3 =^ 

2 H ^ -I 

'3' 

^ ^ ^ .-^ .2 

3 a u §1 



o ca fH 

> a ^ 



§ 3 S 2 ^ 

^ fl ^ ^ 

'"' 'SJ , 

° g «^ « ^ 

CD 53 =^ D 

;^ 2^ >;-2 fl 

^ fl ^ ^ fl 

fl^ fl g fl 



^ fl 



a M §3 ^ 

«2 ^ fl g 



f5.2 



03 ® g 



S ^ rry ^ fl 

O rH rfl "2 ^ fl 

T-^ a i g - 



o .fl > +^ ^ 

S c3 'o 

> cu .fl ^ 

« ^ ^ ^ 



" .2 



•sj9:)}'Bra pnos 


Grs. 

511 

333 
874 

899 
1142 

.376 
174 

306 
481 

572 




Grs. . 

7618 

4764 
12383 

14475 
19240 

6230 
4946 
4292 
9238 

Si39 


•8TIIjn JO 


1020.0 

1019.6 
1019.8 

1019.0 
1019.3 
1020.0 

1024.0 

1022.0 

1025.0 
1016.5 
1018.2 
1022.2 
1020.0 

1018.0 

lo'l'o.o 

1008.0 


-jnoq p9i8.ioxe 
anun jo l^uiv 


£, • •-< ^ '"^ 05 -H • • • O CO 'J3 C r-( -O r-< -f (>T 

^ • o OO <ji <Ji ' • . coeoicc^Ttioooocoos 


•s.iuoH 
Sot 

-JTlp pO^O.tOXO 

onijii JO liOiY 


O CO-H r^-H. . . C:OC51^ HOOlO-M-H-^-t* 

1-1 CM • • p-l(M rHC<) r-lC^IM(M(N 


Grs. 

8160 

5098 
13258 

15285 
20383 

1.5375 
6607 
5121 
4599 
9720 
4080 
8712 
15903 
24240 
32320 
23300 


•enSaoj jepnn 


105.00° 

105.00 

104.80 

102.50 
10L50 

100.00 

102.00 
99.00 
99.00 
99.00 

99.00 
99.00 
99.00 
99.00 

99 J2 


JO e.in^'B.iodinaj, 


103.00° 

103.25 

104.00 

100.75 
99! 16 

97.00 

99.00 
94.50 
96,00 
97.00 

95.90 
96.00 
96.25 
97.00 

9 7! 80 


•ojaqdsoraj-B 
JO o.mj'B.iedaiax 


80.0° 

82.0 

81.0 

83.0 
83.0 

85.0 

■ 87.0 
84.0 
87.0 
87.0 

87.0 
84.5 
86.0 
88.5 

84.'o 

i 


•n0I|'BJTdS92J 


0 CD (M CD 

^* '^•CO CO ^? 0C-til:^'^''.CO-+<-+'-H.(M 
A<- O* Cd"^ ^ CD (M<M<M,^'!M(MC-^<M.(M 
CO Tt< (M (M !M 


•osinj: 


0 00 O' O-O (M 0 00Ot>CD.t^'+'-H<^.-H 

05 CO O) • • t~ >o CD 100-*^ • Tt< -t* ^ 


State of 
Skin. 


Dry, hot. 

Dry, harsh, 
hot 

Moist, hot. 
Moist. 

Normal. 
Do. 
Do. 
Do. 

Normal. 
Do. 


K 
ti 

c; 
!«!; 
o 

o 

H 


Dry, red; superior portion 
coated with black fur. 

Dry, red, and glazed ; 
feels rough. 

Tip clean and red; supe- 
rior portion coated with 
dark fur. 

Cleaner and moist ; still 
red at tip and edges. 

Moist; still redder than 
normal. 

Do. do. 

Slightly coated with yel- 
low fur. 
Normal. 

Do. 

Do. 

Do. 

Normal. 
Do. 


Medicines. 


Sulphate of quinia gr. xx, 

soda powders. 
Soda powders, sulphate of 

quinia gr. x. 

Calomel gr. xij, castor oil in 
4 hrs., sulph. qui. gr. xl. 

Sulphate of quinia gr. xv, 
snakeroot tea f5xvj, table- 
spoonful every 4 hours. 

Brandy, sulphate of quinia, 
and snakeroot tea. 
Do. do. 

Do. do. 
Quas. & soda, snakeroot tea. 
Do. do. 
Do. do. 

Quas. & soda, snakeroot tea. 
Do. do. 


Hour of 

DAY. 


7 P. M. 

11 A. M. 
7 P. M. 

12 M. 

9 P. M. 

11 A. M. 

6 P. M. 

1 P. M. 

10 A. M. 

7 P. M. 

12 M. 
12 M. 

8 P. M. 

11 A. M. 

12 M. 
12 M. 
12 M. 
12 M. 


Date. 


2 !^ III S 2 ?H ^ Ih !2 S S S S S M 



MALAKIAL FEVER. 



o 
O 



Deposits in Urine. 


After 40 hours, a very small 
deposit of prismatic crystals 
of triple phosphate. 

Do. and urate of soda. 

Do. do. 

Do. do. 

Moderately heavy deposit of 
triple phosphate, and urate 
of soda and ammonia. 

Do. do. 
Heavy deposit. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 


•auTiBiii'B 0^ pio-B 
oqj niojj oSu-Bqo 
oq; joj pejinb 
-8J 9nii^ JO -q^SuQi 


• O O O O • • O iC o »c o 


Color of Urine. 


High colored, 
like new Ma- 
deira wine. 
Do. do. 

Brownish red. 

Orange colored. 

Do. do. 
Do. do. 

Deep orange. 
Orange. 
Light orange. 
Nearly normal. 

Normal. 
Do. 
Do. 
Do. 
Do. 


■sjnoq fz 
loj siti8ti:jt;suoo 
onn'BS paxp jo 
jTiTiota'B pa^'B^no^'BQ 


52 • O -H . t~- . • • • O i-H i.T O • • CO • • • • 
• CO O • OS • • • . Tt< CO >o ^ • • o • • • • 

O rH CI 


•sjnoq fZ JOj 
s.TO^'Bni Snuoxoo 
pn'B 9at;o'bj?X9 jo 
^unoux-B paj'Bxnox'BO 


Grs. 
253 

270 
134 

147 

252 
160 


•sjTioq 
fZ loj pio'B oun JO 
;nnorau pe^'BiTioi'BO 


2 'CO CO -Tit • . . . t> C O • • rH .... 

O «3 cJ ic as eo o' 


•sjnoq 

fZ JOJ 'BOJtl JO 

■junoni'B pgj'BXTiDX'BO 


Grs. 
623 

800 

679 
267 
140 
212 

197 


•sjnoq fZ JOJ 

SJ3}5^lU pnOS JO 

:)unoni'B po:)'Bxnox'B3 


2 .m • ' ■ ...oOCO'-rH.... 
^ .00 03 . p-i . . . . .^^^ . .^5 . . . . 


•sjnot[ 

JOJ JO^'BAl. JO 

^Tinoni'B paj'BxnoxBQ 


00 -+I 'O -H CO 1>- M 
OQ . (M c: . CO . . . . . 00 CO O . . <M . . . . 
ti .•^ (M.-M... ..0^0..0.... 

^r-<^o t^!^ocoeo 


•s.moq 
fZ JOJ onijn JO 
jnxioni'B pa^'BXTiox'BQ 


Grs. 
12240 

15294 
21567 

8*038 

13652 
6490 

12240 
13940 


-uoo euix'BS psxt^i 


00. 0 ccooooo., .'-"JOOiMCO.i-l.... 
S-( , (M r-l 00 O , . ; CO (M (M CO IQ .CD . ! I . 
O rHM r-l 


•sjo^^'Bni Sutjoxoo 
pu-e oAip'BJjxg; 


00. 00 OCOiO»0.. . CO^O-H T— ( 

s-i.cD oloojco.. ..cNa><MrH,oo;.:: 

r-l <N ,-1 rH rH * * * * 


•piO'B oiixi 


Grs. 
3*. 20 

1.45 
4.65 
6.00 
7.45 

8*55 
4.22 
6.25 
2.70 
8.95 

5!69 
35.65 




C0.O5 COfMlr^O., .ODCKMOeO.CO.... 

^ CO (M O O t~ iO C<) i-< Cq rl 


Hour of 

DAY. 


7 p. M. 

11 A. M. 

7 p. M. 

12 M. 

9 P. M. 

11 A. M. 

6 P. M. 
1 P. M. 

10 A. M. 

7 P. M. 

12 M. 
12 M. 

8 P. M. 

11 A. M. 

12 M. 
12 M. 
12 M. 
12 M. 


Date. 


OrH pH IM (MCO CO-^i;5»nCOCDCDt^G0050S<l 
r-< T-i rH rH r-l rH rH rH rH rH rH rH rH rH rH <M 



320 



OBSERVATIONS ON 



Observation. — (x.) Irish seaman; age 21 ; height 5 feet 4 inches; 
weight 125 pounds ; brown hair, brown eves, sallow complexion. 
Has been in Savannah three weeks, and has been sick three days. 
This is his first trip to Savannah during the summer season. 

Oct. 12, 12 M. Complains of great weakness and pain in his back 
and bones ; says that he had no chill and no fever during the three 
days of indisposition previous to his entrance into the hospital. 
Pulse 80, fall. 

R. — Sulph. of quinia gr. v every three hours up to gr. xv. 

18th, 12 M. Did not rest well last night. Complains of pain in 
his head and bones. Had a chill two hours ago. Tongue clean, 
red, dry, and rough; papillae enlarged. Some tenderness of epi- 
gastrium. Skin hot and dry. Pulse, 118 ; respirations 24 to 26, 
irregular, thoracic. 

B. — Calomel gr. x. Follow with castor oil in four hours. 

R. — After fever remits give sulphate of quinia gr. v every three 
hours up to gr. xx. 

14th, 12 M. Medicine acted twice. Tongue clean and very red. 
Patient is not so restless; complains of great weakness; has taken 
gr. XX of sulphate of quinia. Temperature of skin normal. 

R. — Brandy flviij ; sulph. of quinia gr. xv ; infusion of Yirginia 
snakeroot fsviij. — Mix. Tablespoonful every four hours. 

15th, 12 M. Had an increase of fever yesterday afternoon, which 
was accompanied with severe pain in his head and bones. 

Now he is restless and nervous ; countenance uneasy, anxious. 
All his motions are indicative of restless, uneasy, anxious feeling; 
complains of great thirst ; tongue as red as scarlet, at 9 o'clock 
this morning it was dry and glazed, at the present time (three 
hours afterwards) it is a little moister and softer ; lips dry, red, 
and rough. Epigastrium tender upon pressure ; trunk and head 
very hot ; extremities only moderately warm. Complains of pain 
in the small of the back, and in the knees and bones of his 
legs. Pulse 106, feeble ; respirations 80 to 84, irregular, labored, 
thoracic, panting. Temperature of atmosphere, 74^ F. ; temp, of 
hand, 101° ; temp, on axilla, 105°. The temperature under the 
tongue could not be taken on account of his restlessness. There is 
a great want of co-ordination between the circulation, respiration, 
and temperature of the extremities. The capillary circulation and 
chemical changes are impeded. Eeaction of saliva, acid. 

B. — Four cut cups to epigastrium. Four cut cups over the 
lumbar regions and spine. 



MALARIAL FEVER. 



821 



B. — Sinapisms to the extremities. 

Urine high-colored, of a deep brownish-red color. Sp. gr., 1028 ; 
reaction decidedly acid. 

Amount of urine passed during tlie last 30 hours . . 15,430 grs. 

" " " " 24 " . . 12,344 " 

" " hourly " " 515 " 





15,430 grains of 
urine, passed 
during 30 hours, 
contained 


12,34-i grains of 
urine, passed 
during 24 hours, 
contained 


1000 parts of urine 
contained 


Urea 

Uric acid .... 
Fixed saline constituents 


Grains. 

727.500 
9.300 
75.000 


Grains. 
582.000 
7.440 
60.000 


47.178 
0.603 
4.863 



7 J o'clock P. M. Lies in a stupor, muttering to himself, and is 
with great diflQculty aroused. When aroused, answers incoherently 
and says that he feels very well. Temperature of extremities below 
the normal standard, cool ; temperature of head and trunk normal ; 
tongue of a bright red color ; great tenderness of epigastrium ; pres- 
sure here arouses him more quickly than violent shaking. Pulse 
100, feeble; respirations, 32. 

R. — Two cut cups to each temple. B. — Blister over the epigas- 
trium, 6 inches by 4 inches, and another to the back of the neck, 
4 inches by 5. B. — Apply sinapisms to extremities. B. — Brandy 
and infusion of Virginia snakeroot, and spirit of mindererus, f^ss; 
of each alternately every half hour, until reaction is established. 
B. — Sulph. of quinia, gr. v, every three hours up to gr. xlv. 

Amount of urine passed during the last 7^ hours . . 4,072 grs. 

" hourly " " . . 543 " 

Calculated amount of urine for 24 hours . . . 13,030 " 

Sp. gr. of urine 1018 ; high colored and strongly acid. After stand- 
ing 70 hours there was no deposit, and the reaction w^as still de- 
cidedly acid. 





4072 grains of 
urine, passed 
during 7^ hours, 
contained 


13,030 grains of 
urine, calculated 
for 24 hours, 
contained 


1000 parts of urine 
contained 


Urea . . . . . 

Uric acid .... 


Grains. 
151.320 
1.888 


Grains. 

483.224 
6.036 


37.161 
0.461 



Oct. 16th, 9 o'clock A.M. Much better; intellect clear. The 
cups, blisters, and stimulants, and sulphate of quinia, have restored 
the capillary circulation to its normal state. 



322 



OBSERVATIONS ON 



12 J o'clock P. M. ContiDues to improve ; urine high-colored, of 
a deep orange-red ; reaction strongly acid ; after standing fifteen 
hours, a slight deposit of mucus-corpuscles ; and after one hundred 
hours, a small light yellow deposit of mucus-corpuscles, urate of 
ammonia and vegetable cells. The presence of the mucus-corpus- 
cles in the urine is due to the absorption and action of the cantha- 
radin upon the mucous membrane of the genito-urinary apparatus. 
In several cases of severe remittent fever, I have discovered, after 
the action of blisters, numerous spermatozoa in the urine. Sp. gr. 
of urine, 1021. 





11,231 grains of 
urine, passed 

during the last 
16 hours, 
contained 


16,746 grains of 
urine, calculated 
for 24 hours, 
contained 


15,303 grains of 
urine, excreted 
during 24 hours, 
contained 


1000 parts of 
urine contained 


Urea .... 
Uric acid 

Fixed saline constituents 


Grains. 

357.445 
5.500 
53.900 


Grains. 

535.667 
8.250 
80.850 


Grains. 

508.760 
7.380 
64.680 


31.820 
0.489 
4.799 



Amount of urine passed during tlie last 16 hours, . . 11,231 grs. 

" " hourly " " . . . 702 " 

Calculated amount of urine for 24 hours, .... 16,746 " 

Actual amount of urine excreted during the last 24 hours, . 15,303 " 

" " " hourly " " . 637 " 

3 o'clock P. M. Skin dry but soft. Has taken xlv grs. of sul- 
phate of quinia. This has not yet exerted its characteristic effects 
upon the skin. Tongue red but moist and soft ; blisters have drawn 
well. Serum from blistered surfaces of a golden color; patient 
complains of difficulty in passing his urine. This is due to the 
absorption and action upon the mucous membrane of the bladder 
and urethra, of the cantharidin absorbed from the blistered sur- 
faces. Pulse, 84; respiration, 16. Temperature of atmosphere, 
69.5° F. ; temp, of hand, 99° ; temp, under tongue, 99.5°. R.— Sul- 
phate of quinia, gr. v, every three hours, up to gr. xv. R. — Con- 
tinue spirit of mindererus, and brandy, and snakeroot tea, f^ss of 
each alternately every two hours. Diet, mutton soup and arrow- 
root. 

17th, 12 M. Continues to improve; tongue red, but clean and 
soft. Pulse 70; respiration 16. Temperature of atmosphere, 67° 
F.; temp, of hand, 97.33°; temp, under tongue, 98.5°. Color of 
urine deep red, reaction decidedly acid. Sp. gr. 1022. Eeaction 
of saliva strongly acid. 



MALARIAL FEVER. 



32a 



Amount of urine passed 



during tlie last 24 hours . . 8176 grs. 
hourly " " . . 382 " 





8176 grains of urine, 
excreted during 24 
hours, contained 


1000 parts of urine 
contained 


Fixed saline constituents 


Grains. 

185.240 
4.400 
40.000 


22.578 
0.538 
4.892 



The reduction of the temperature, and of the action of the respi- 
ratory and circulatory system, has been attended by a correspond- 
ing diminution of the constituents of the urine. 

18th. Continues to improve; "feels quite well, with the excep- 
tion of great weakness." His appetite has returned ; tongue clean, 
moist, and soft, and not so red. Pulse 72 ; respiration 18. 

R. — Continue brandy and infusion of Virginia snakeroot. 

Color of urine orange, much lighter ; reaction in twenty hours, 
decidedly alkaline. Sp. gr. 1020. Heavy light yellow deposit, after 
standing twenty hours, of urate of soda and triple phosphate. 

Amount of urine passed during the last 24 hours . . 20,400 grs. 
" " hourly u u ^ ^ 850 " 

Diet, soft-boiled eggs, milk punch, arrowroot, and mutton soup. 

18th, 12 M. Skin, pulse, and respiration normal. Urine orange 
colored. Sp. gr. 1020. Eeaction alkaline in tv/elve hours ; heavy 
light yellow deposit in twelve hours. 



Amount of urine excreted during the last 24 hours 
" " hourly " " 

20th. 

Amount of urine passed during the last 24 hours . 
" " hourly " " 



15,300 grs. 
637 " 



17,374 grs. 
724 " 





17,374 grains of urine, 
passed during 24 
hours, contained 


1000 parts of urine 
contained 


Fixed saline constituents 


Grains. 

11.730 
93.500 


0.675 
5.381 



Sp. gr. of urine 1022. Eeaction alkaline in twelve hours ; orange 
color. After standing twenty-four hours, a light yellow deposit of 
triple phosphate and urate of soda were thrown down. 

21st, 9 A. M. The patient is dressed, and has been walking about 
the hospital grounds. His pale, sallow complexion and feeble gait 



324 



OBSEKVATIONS ON 



show the effects of the malarial fever. Urine of a light orange 
color, only a shade darker than normal. Sp. gr. 1024. Eeaction, 
just after its deposition, acid; in ten hours afterwards, alkaline. 
This change gave evidence of the formation of ammonia, and was 
attended by the formation of crystals, presenting, when the urine 
was held in the sun, a sparkling appearance, like particles of silver. 
Under the microscope these crystals were found to be well formed, 
prysmatic crystals of triple phosphate. The microscope also re- 
vealed a few crystals and globular masses of the urates of soda and 
ammonia. 





9234 grains of 
urine, excreted 
during 12 hours, 
contained 


18,468 grains of 
urine, calculated 
for 24 hours, 
contained 


1000 parts of urine 
contained 


Urea 

Uric acid .... 
Fixed saline constituents 


Grains. 

229.599 
7.740 
91.800 


Grains. 

458.198 
15.480 
183.600 


25.128 
0.935 
9.941 



Amount of urine passed during 12 hours . . . 9,234 grs. 

" " hourly " ... 769 " 
Calculated amount for 24 hours 18,468 " 

The following table will present the relations of the pulse, respi- 
ration, and urine : — 



MALARIAL FEVER. 



325 



Reaction, Deposits 
IN Ukine, &c. 


No deposit after 110 
hours. 

Do. do. 

After 15 hours, a small 
deposit of mucus-cor- 
puscles ; after 100 hrs., 
small deposit of vege- 
tative cells and urate 
of soda. 

Heavy deposit of urate 
of soda and triple phos- 
phate, and alkaline re- 
action after 20 hours. 
Do. do. 

Reaction alkaline in 12 
hours ; heavy deposit. 

Reaction changed from 
acid to alkaline in 10 
hours; heavy deposit 
of urate of soda, and 
ammonia, and triple 
phosphate. 


Color of 
Urine. 


Deep 
brownish 
red color. 
Do. 
Deep 
orange. 

Deep red. 
Orange. 

Do. 

Light 
orange. 
Very light 
orange, 
almost 
normal 

color. 


•s.moq fz 
joj s^nonmsuoo 
etiix'Bs paxg jo 

^TttlOtn'B pO^H^TlOIHQ 


Grs. 
80'.850 

183.600 


•sitioq 

fZ .TOJ piO'B OTjn JO 

^nnoui'B pa^'Bitioi'BQ 


Grs. 

6.036 
8.250 

15.480 


•s.Tiioq 

fZ -lOJ 'BOItl JO 

^Tinora'B po^'Bitiax'BO 


Grs. 

483.22 
535.60 

458.10 


•s.inoq 
fZ JOJ anun JO 
^ntiooi'B popino^'BQ 


Grs. 

13030 
16746 

18468 


•s;noTHi:js 
-noo onn'BS poxij 


Grs. 

7.5.00 
60.00 

53V9O 
61.65 

40.00 

93.50 
91.80 




Grs. 

9.300 
7.440 

1.888 
5.500 
7.380 

4.400 

11.730 
7.740 




Grs. 

727!50 
582.00 

151.32 
357.44 
508.70 

185.20 
229.50 


•SJTIOJJ 

Tit pa'jeioxo 
snijn JO ^unoOTy 


•COIN r-i<M IM(M Cqoq rH 


Grs. 

15430 
12344 

4072 
11231 
15313 

8176 
20400 

15300 
17374 

9234 


•onun 
JO ^JIA'B.lS oifioodg 


1028 

1018 
1021 
1021 

1022 
1020 

1020 
1022 

1024 


•OTiSno:) jtop 
-tin oiTH'B.iedniex 


105.0° 

98.5 

Normal 
Normal 

Normal 


•pn'Bq 
JO e.in^'B.iodnioj;, 


ioV.o° 
99! 0 

97.33 

Normal 
Normal 

Normal 


•8.T9i];dsoin:>B 
JO o.tn^'B.ioduioj, 


74.00 
69.5 

67.0 


•noi^'BJidsaa; 


24-26 
30-40 

32 
16 

16 
16 

Normal 
Normal 

Normal 




118 
106 

100 

84 

70 
72- 

Normal 
Normal 

Normal 


Hour 

OF DAY. 


(M (M -iccq (M cq c<l (M (M 05 
PH i-H rH r:^ rH rH r-^ r-l rH 


H 
El 
< 
ft 


C0iO>O>OCDCO 030rH 
r-<^^-^ rHrlrH rH rH rH (M IM 

0 



826 



OBSEEVATIONS ON 



Observation, — (?/.) Irish seaman, aged 38; weight 160 lbs.; height 
5 feet 6 inches ; stout, muscular man ; first trip to Savannah. Has 
been in Savannah ten days, during which time he has worked on 
a ship lying along the shore of the river, and has slept on Bay 
Street at night. 

Oct. 14, 2 P. M. Was taken sick four days ago, Vv^ith pain in his 
head and in all his bones, accompanied with fever, which has con- 
tinued unabated up to the present time. Has had no chill. Took 
a dose of calomel three days ago, which acted freely. Now his face 
is much flushed; skin hot and dry; head very hot; complains 
greatly of pain in his head; eyes look heavy and stupid; tongue 
bright red and dry; voice hoarse and guttural; says that he has 
been vomiting, and can retain nothing upon his stomach. B. — Cut 
cups to each temple, and two to back of neck, and four over the 
region of the stomach. 

If the cut cups do not relieve the vomiting, administer a table- 
spoonful of equal parts of milk, lime-water, and the aqueous solu- 
tion of the acetate of morphia. 

15th, 11 A.M. Says that he feels better; the cut cups over the 
temples and back of neck relieved the pain in his head, and the 
cut cups over the region of the stomach checked the vomiting. 
Face is not so much flushed; tongue still very red, dry, and rough ; 
no tenderness upon pressure of epigastrium, although the state of 
his tongue would lead us to look for it ; skin soft and not so hot. 
This morning at 3 A. M. the fever remitted with perspiration. 
Pulse, 76 ; respiration, 20. Has taken xxvj grains of sulphate of 
quinia. R. — ISTeutral mixture ; drink ad libitum. 

8 o'clock P. M. Has been vomiting this evening. This was ar- 
rested by milk and limiC-water, and acetate of morphia. Tip of 
tongue for three-fourths of an inch clean, dry, glazed, and of a 
brilliant red color — the remainder of the tongue is coated with 
brownish-yellow fur, which is dry and harsh to the feeling ; face 
flushed and hot ; skin, upon all parts of the body, hot, pungent, and 
dry; no tenderness upon pressure of epigastrium. The calomel has 
acted several times, and is still acting. Pulse, 94 ; respiration, 26. 
B. — Soda powders. Urine high colored, like new Madeira wine. 

16th, 1 o'clock P. M. Did not rest during the night ; was tossing 
about, and getting up out of the bed every few moments, and was 
and is now tormented by unquenchable thirst; appears to be com- 
pletely exhausted. Tip of tongue clean, dry, scarlet-colored, glazed, 
shining — posterior portion (base) of tongue coated with brown and 



MALAEIAL FEVEE. 



327 



black far, dry, harsh, and as rough as sand-paper. The under sur- 
face of the tongue is dry, glazed, and shining. There is no more 
moisture in his tongue, and in the walls of the mouth, than if they 
were made of glass. Skin hot, dry, and harsh to the feeling. 

The temperature under the tongue cannot be taken, on account 
of the dry condition of the lips and tongue. Bowels are loose — 
stools watery and yellow ; no pain upon pressure of epigastrium. 
Complains of no pain anywhere. There is a great tendency to 
stupor. 

Although his tongue is glowing red, and his face is flushed, and 
there is an inclination to stupor, still I will administer sulphate of 
quinia and stimulants, because he is exhausted, and the appearance 
of the mucous membrane of his mouth and tongue is indicative, not 
of inflammation, but of derangement of the capillary circulation, and 
of alterations in the nervous system and blood. 

B. — Brandy f^viij; infusion of Virginia snakeroot fsviij; sul- 
phate of quinia gr. xv. — Mix. f^j every hour. R. — Spirit of 
minder eras f^j every hour. B. — Mustards to extremities. B. — 
Sulphate of quinia gr. v; camphor gr. ij. — Mix. Every three hours. 
R. — Soda powders. 

Amount of urine passed during the last 17 hours . . 10,210 grs. 

" " hourly " « . . 600 " 

Calculated amount of urine for 24 hours . . . 14,406 " 

Sp. gr. 1020. Reaction decidedly acid; urine high colored, like 
new Madeira wine. N"o deposit after thirty hours; after sixty 
hours, a slight deposit of mucous corpuscles and triple phosphate. 
Crystals of nitrate of urea, silvery and well formed. Hydrochloric 
acid showed the presence of coloring matters in large amount. 





10,210 grains of 
urine, excreted 
during 17 hours, 
contained 


14,406 grains of 
urine, calculated 
for 24 hours, 
contained 


1000 parts of urine 
contained 


Urea 

Uric acid .... 
Fixed saline constituents 


Grains. 
320.980 
0.200 
30.000 


Grains. 

452.581 
0.382 
40.330 


32.305 
0.019 
2.938 



17th, 11 o'clock A.M. Much better. Tip of tongue clean — supe- 
rior portion coated with fur; tongue moister, softer, and not so red 
as on yesterday; face much less flushed; the burning thirst has 
almost entirely disappeared ; has no pain anywhere, and says that 
he has an appetite; no tenderness of epigastrium. Has taken grs. 
XXX of the sulphate of quinia since 1 o'clock P.M., October 16th. 



328 



OBSERVATIONS ON 



Pulse, 68 ; respiration, 18. Pulse mucli fuller ; respiration more 
regular aad soft. Temperature of atmosphere 68° P.; temperature 
of hand 98°; temp, under tongue 98°.5. 

Here we see, that under the action of the sulphate of quinia and 
stimulants, his respiration has become regular; his pulse slower 
and fuller; his burning thirst diminished; his glowing tongue and 
flushed face paler ; his parched mouth moister ; his intellect brighter ; 
his exhausted forces more active; and all the secretions and func- 
tions more regular. Urine high colored. Decided acid reaction. 
Sp. gr. 1022. No deposit after standing thirty hours. After eighty- 
hours a small light-yellow deposit of triple phosphate and urate of 
soda. 

Amount of urine excreted during the last 24 liours . 12,264 grs. 
" " hourly " " . . 511 





12,26-1 grains of urine, 
passed during 2i 
hours, contained 


1000 parts of urine 
contained 


Fixed saline constituents 


Grains. 
315.250 
5.200 
34.800 


30.846 
0.440 
2.846 



B. — Continue camphor and sulphate of quinia, and brandy and 
snakeroot tea. Diet, milk-punch, wine-whey, arrowroot, and mut- 
ton soup. 

18th, 12 o'clock M. Eested well during the night; had no fever, 
and his skin was in a good perspiration. The great thirst has 
entirely disappeared. Tongue still redder than normal, but moist 
and soft, and the yellow fur coating the posterior portion is break- 
ing np and cleaning off; skin moist, and normal in temperature 
and feeling. Pulse and respiration normal. Dressed himself, and 
has been walking in the ward. Urine of a deep orange color, 
several shades lighter than that voided yesterday. Sp. gr. 1019. 
Eeaction slightly acid. 

Amount of urine passed during the last 24 hours . . 12,737 grs. 
" " hourly « " . . 614 " 

R. — Continue brandy and snakeroot tea, tablespoonful every 
three hours. Diet, soft-boiled eggs, milk punch, mutton soup, 
arrowroot, and rice. 

19th. Dressed, and walked about the ward. 

20th. Walked about one mile into town ; says that he feels well ; 
urine orange color. Sp. gr. 1020. After standing twelve hours, a 



MALAKIAL FEVER. 829 

heavy light-yellow deposit of triple phosphate and urate of soda. 
1000 parts of urine contained uric acid 0.607. Fixed saline consti- 
tuents 8.529. 

21st. Says that he took a slight cold yesterday, during the walk 
into the city ; urine orange color. Sp. gr. 1019. 

Amount of urine passed during the last 17 liours . ^ . 13,247 grs. 

" " hourly " " .' . 770 " 

Calculated amount of urine for 24 liours . • . ■. . 19,495 " 





13,247 grains of 
urine, excreted 
during 17 hours, 
contained 


19,595 grains of 
urine, calculated 
for 24 hours, 
contained 


1000 parts of urine 
contained 


Urea ..... 

Uric acid .... 
Fixed saline constituents 


Grains. 
181.568 
6.110 
96.900 


Grains. 
290.508 
9.770 
154.040 


12.992 
0.461 
7.199 



This patient had no return of fever, and was discharged a few 
days subsequently. This case sustains not only the conclusions, 
but also the treatment of the two preceding cases of remittent fever. 

Six Cases from the same Small Yessel, illustrating the Injurious 
Effects of the Use of Calomel, and the neglect of Stimulants 
AND Sulphate of Quinia in Remittent Fever ; the Relations op 
the Pulse and Respiration and Temperature in Malarial Fever ; 
the Effects op Stimulants and Sulphate op Quinia upon the 
severe Cerebral Symptoms; the Depressing Influences op the 
Malarial Poison; and the Diversity op the Manifestation of 
its Effects in Men living in the same Small Yessels, and ex- 
posed, IN AN EQUAL MANNER, TO THE MaLARIAL INFLUENCE. 

Observation. — {x 1.) American seaman from U. S. cutter ; age, 24 ; 
height, 5 feet 10 inches ; weight, 150 pounds ; brown hair, brown 
eyes. This is his first summer in Savannah. Has been employed 
as a sailor on the United States revenue cutter, which has been 
cruising during the summer, up and down the Savannah River. 

Ten days ago, the cutter was struck by lightning and was placed 
in the dry dock, at the ship yard, on the river, east of the city. 
This ship yard is located on the Savannah River, about five hun- 
dred yards from the eastern boundary of the city in a malarious 
district which was formerly under the rice (wet) culture ; now the 
surrounding lowlands are protected from overflows by dams, and 
are under dry culture. The banks of the river, at this locality, are 
22 



830 



OBSERVATIONS ON 



coated with mud composed in large measure of animal and vege- 
table matters ; the banks and bottom of the canal, in which the 
ships are floated at high water, also contain large quantities of 
similar mud. The crew of the cutter slept on board one night after 
she was placed in dry dock. The crew consisted of ten healthy 
seamen, and out of this number six were taken sick in the course 
of ten days. Whilst the cutter continued in the stream the men 
were healthy, but as soon as they were exposed to the exhalations 
of the mud, and low grounds, they were taken sick. 

September 24, 1857. lias just entered the hospital, and says that 
he had a slight chill yesterday, followed by fever. Tongue coated 
with brownish-yellow dry fur. Pulse, rapid ; intellect, dull. Says 
that his bowels have not been moved for several days. 

R. — Calomel gr. xv; castor oil in four hours. 

2oth. Medicine acted freely. Has fever. Tongue still coated 
with fur, but a little more moist. The fur shows a disposition to 
come off in patches. Pulse, accelerated; intellect continues dull. 

R. — Sulph. of quinia gr. v, every three hours, up to gr. xv. 
Soda powders. 

26th. Has been passing his feces in bed, and lies in a comatose 
condition. 

Be. — Cut-cups to back of head. B. — Sinapisms to extremities; 
blisters to back of neck and epigastric region. B. — Infusion of 
snakeroot, and sulphate of quinia. R. — Calomel gr. xxiv; opium 
gr. ij. — Mix. Divide into twelve pills, and administer one every 
two hours. 

27th. Continues comatose. Pulse 106, small and feeble. The 
blisters drew finely. The hlisters and sinapisms failed, to arouse this 
'patient^ and he died this afternoon at 1 o^cloch P. M. 

AUTOPSY TWENTY HOURS AFTER DEATH. 

Exterior. — Full ; limbs round ; subject apparently not at all 
emaciated ; skin of the superior (uppermost) portions of the body 
presented the usual appearance, whilst the skin of the inferior (de- 
pendent) parts presented a mottled, purplish appearance. This 
W'as due to the settling of the blood under the action of gravity. 

Head. — Dura mater presented the usual appearance. 

Arachnoid membrane not opalescent, but presented the usual 
transparency. Bloody serum was effused between the arachnoid 
membrane and pia mater. 

Bloodvessels of pia mater congested with blood. 



MALAKIAL FEVER. 



331 



Ventricles of brain, almost completely filled with reddish serum. 
Bloodvessels of the superior portions of the brain, more congested 
with blood than those of the inferior portions. 

Substance of the brain presented the usual appearance and con- 
sistency, considering the length of time since death. 

Chest. — Heart and lungs normal. 

Abdomen — Liver. — Color of the exterior appeared to be normal 
(perhaps a shade darker than usual), with the exception of two 
slate-colored spots. The largest of these slate-colored spots was 
four inches in diameter, and situated upon the anterior surface of 
the right lobe, whilst the smallest was situated upon the posterior 
surface of the left lobe. When an incision was made into the sur- 
face of the liver, through these spots, the structures presented a 
bronze color for the depth of a quarter of an inch. In all other 
parts of the liver, the cut surface presented a color only a shade 
deeper than normal. 

Spleen^ enlarged, softened, and of a dark slate color. 

When the mud of the spleen was exposed to the atmosphere, a 
part retained the dark-purplish and reddish-brown color, whilst 
another smaller portion changed to an arterial hue. The differ- 
ence between these two portions of the splenic mud were clearly 
seen when a section of the organ was exposed for several hours to 
the action of the atmosphere. The other portion of the mud of the 
spleen did not change its color. It is probable that this pheno- 
menon was due to the fact, that the blood had been but recently 
effused into the spleen. The portions first effused had lost the 
power of changing to the arterial hue, whilst those last effused had 
not lost this power. 

Kidneys, normal. 

Alimentary Canal. — The mucous membrane of the alimentary 
canal, from the oesophagus to the anus, presented the normal color, 
and showed no signs whatever of congestion or inflammation. 

CONCLUSIONS. 

(1.) This case illustrates the rapid and powerful action of the 
malarial poison. 

(2.) The brain and its membranes appeared to be normal, with 
the exception of the serous effusion which was entirely inade- 
quate to account for the cerebral disturbance during life; the 
liver, with the exception of the small spots, appeared to be normal 
in structure ; the affection of the spleen was recent ; and the all- 



332 



OBSERVATIONS ON 



mentary canal, from the mouth to the anus, bore no marks of in- 
flammation, and yet this strong, hearty young man fell a victim to 
the malarial poison. 

The malarial poison appeared to act in this case, directly upon 
the nervous centres of the cerebro-spinal and sympathetic nervous 
systems. 

(3.) The treatment of this case was radically defective — it was 
wanting in energy. The effects of the disease were those of exhaustion^ 
and not of inflammation and excitement. The chemical changes of the 
elements were interfered luith^ and the relations of the forces^ as a 
necessary consequence^ disturbed. The manifest indication was to stimu- 
late the exhausted nervous system^ and excite those chemical changes hy 
which the forces are generated^ which work the animal machinery. 

The blisters and sinapisms, and cut-cups, and small doses of 
sulphate of quinia, were right, as far as they went. The last doses 
of calomel were decidedly wrong, and worse than useless ; they 
simply worked in conjunction with the malarial poison. Large 
doses of brandy, carbonate of ammonia and sulphate of quinia, 
should have been administered promptly and energetically, in con- 
junction with the blisters and sinapisms. The following case, 
which resembled this one in all respects, will illustrate, in a forcible 
manner, these conclusions : — 

Observation. — {x 2.) Seamen from the United States revenue cut- 
ter, and a shipmate of the previous case ; and the remarks which 
were made with reference to the history of that case, apply also to 
the present one. Age 26 ; light hair, blue eyes, florid complexion ; 
height, 5 feet 11 inches ; weight, 160 lbs. This is his first sum- 
mer in these regions. 

September 25, 1857. Has been sick two days; says that he was 
suffering with a thick eruption of prickly-heat. This disappeared 
suddenly and then the fever appeared. Has fever now. 

R. — Calomel gr. xv ; castor oil in four hours. 

26th. Medicine acted freely ; heat of skin much less ; tongue 
heavily coated with yellow fur, tip and edges very red ; intellect 
dull ; appears to articulate with difficulty. 

R. — Sulph. of quinia, gr. v every three hours, up to gr. xv. In- 
fusion of Virginia snakeroot. 

27th. Intellect still dull ; tongue presented the same coated ap- 
pearance. Pulse 83. 

R. — Calomel gr. x ; sulph. of quinia gr. v. Mix and administer 
immediately. 



MALARIAL FEVER. 



333 



28th, 10 o'clock A. M. Was delirious during the night, and it 
was necessary to use much force to keep him in bed. Appears to be 
much worse this morning, and continues delirious ; tongue, heavily 
coated and very red at tip and edges. Pulse, 86. No pain upon 
pressure of epigastrium. 

R. — Blister to epigastrium and back of neck. R. — Calomel gr. 
xxiv ; opium gr. ij. — Mix. Divide into twelve powders, and ad- 
minister one every two hours. 

7 o'clock P. M. Appears to be very weak and stupid. When 
aroused by shaking, whines and mutters incoherently. Pulse, 82 ; 
respiration, 20 ; skin dry ; tongue presented the same appearance. 
It is evident that unless the calomel he abandoned, and a more vigorous 
method of treatment adopted^ this patient will die just as the previous 
case. 

R. — Two cut-cups to each temple ; sinapisms to extremities. R. — 
Brandy f^viij ; infusion of Virginia snakeroot fsviij ; sulphate 
of quinia gr. xv. Mix and administer a tablespoonful every half 
hour. R. — Sulph. of quinia gr. v every three hours up to gr. xx. 

29th, 11 o'clock A. M. The stimulants and sulphate of quinia 
have been productive of much good. Tongue, although very red, 
and dryer and rougher than normal, is moister and softer than it 
was yesterday. During the night, slept soundly, and this morning 
his skin relaxed and was bathed in a copious perspiration. Intellect 
clearer. Pulse, 78 ; respirations, 15. Temperature of atmosphere 
80° F. ; temp, of hand, 99. Has taken during the last eighteen 
hours, forty grains of sulphate of quinia. R. — Give 20 more grains 
of sulphate of quinia during the next 20 hours, and continue the 
brandy and infusion of Virginia snakeroot, tablespoonful every 
hour. Diet, beef-soup and tea. 

7 o'clock P. M. Continues to improve, and says that he is mucli 
better. The blisters have drawn and discharged golden colored 
serum. Intellect more active, but still much duller than usual. 
Tongue red, dry and harsh, feels like sand-paper — superior portion 
coated with yellow fur; face much flushed; reaction of saliva de- 
cidedly acid ; urine high colored. Pulse, 80 ; respirations, 16. 
Temperature of atmosphere, 78.5° F. ; temp, of hand, 100.33. 

R. — Mustard to extremities. Stop sulphate of quinia. Continue 
brandy and infusion of Virginia snakeroot. Diet, milk punch, and 
brandy and arrowroot. 

30th. Says that he is much better. Pulse, 79 ; respirations, 16. 
Temperature of atmosphere, 70° F.; temp, of hand, 97.5; temp. 



834 



OBSEKVATIONS ON 



under tongue, 100. Tongue still very red, but more moist. Skin 
dry ; reaction of saliva acid. 

Urine, of a bright red color, and decided acid reaction — sp. gr. 
1022. Uric acid in 1000 parts, 0.538. 

R. — Continue stimulants and nutritious diet. 

Oct. 1st, 11 o'clock A. M. Eested well during the night, and 
continues to improve. Complains of great weakness. Tongue 
much softer. Pulse, 70; respirations, 14. Temperature of atmo- 
sphere, 71*^ F. ; temp, of hand, 98 ; temp, under tongue, 99.5. Urine 
only a shade higher colored than normal, reaction acid — sp. gr. 1010. 
Uric acid in 1000 parts, 0.0099. 

B. — Continue brandy and infusion of snakeroot tea. Administer 
15 grs. of the sulphate of quinia during the next fifteen hours. 

2d, 11 o'clock A. M. Surface of blister red and raw ; tongue 
cleaning off; papillae enlarged and distinct ; bowels torpid. Pulse 
60 ; respirations 13, slow and full. It is probable that the frequency 
of the respiration is diminished by the blistered surface. Temper- 
ature of atmosphere, 76° F. ; temp, of hand, 97.75 ; temp, under 
tongue, 99.5. 

B. — Continue stimulants and nutritious diet, milk punch and 
mutton soup. 

Urine, of a bright red color, sp. gr. 1020 — turbid after standing 
several hours. Amount passed during the last twenty-four hours, 
13,260 grs. 

8d, 11 o'clock A. M. Pulse, 62; respiration, 14. Temperature 
of atmosphere, 76° F.; temp, of hand, 98°; temp, under tongue, 
99.25°. Eeaction of saliva acid ; urine of a deep orange color — 
heavy, light-yellow deposit after standing a few hours. The acid 
has greatly diminished — reaction alkaline after standing a few 
hours. Amount passed during the last twenty-four hours, 15,330 
grs. ; sp. gr. 1022. Uric acid in 15,330 grs, of urine, 10.5 grs. 
Uric acid in 1000 parts of urine, 0.684. Bowels have not been 
moved for four days. 

B. — Calomel gr. viij ; sulph. of quinia gr. v. Castor oil in four 
hours. Continue stimulants and infusion of snakeroot. 

4th. Dressed and walking about the ward. Tongue moist and 
soft, and only a little redder at the tip than usual. Pulse, 60 ; res- 
piration, 12. Blister raw, and slow in healing. Urine orange 
colored, reaction slightly acid, when first voided, but rapidly changes 
to the alkaline, and lets fall a heavy deposit after standing a few 
hours. 



MALARIAL FEVER. 



835 



R. — Quassia and soda. Full diet. 

5th. Urine, orange colored ; sp. gr. 1024. Heavy deposit — reac- 
tion of saliva very slightly acid. 

8th. Entirely restored to health. Pulse, 48 ; respiration, 14. 
Temperature of atmosphere, 73° F.; temp, of hand, 97° ; temp, under 
tongue, 99.5°. 

CONCLUSIONS, 

(1.) Although the pulse of this patient, at first sight, did not ap- 
pear to have been much accelerated, when compared with the pulse 
in other cases of malarial fever, still it was greatly accelerated. The 
pulse was unusually slow in health, only 48 to the minute. The 
respiration was also very slow in health, 14 to the minute. The 
temperature of the surface was not greatly elevated. 

(2.) Aside from the cerebral symptoms, there was nothing to 
alarm the practitioner, except the state of the tongue. The promi- 
nent symptoms, as in the previous fatal case, from the same vessel, 
were connected with the brain. 

(3.) Active purgation and alterative doses of calomel, so far from 
benefiting, were, as was conclusively demonstrated, by careful exa- 
minations and analyses of all his symptoms, working in conjunc- 
tion with the malarial poison, and rapidly bringing on a fatal ter- 
mination. Stimulants, blisters, sinapisms, and large doses of sul- 
phate of quinia, administered without any regard to the state of 
the tongue and brain, so far from increasing the cerebral disturb- 
ance, diminished it rapidly. Under the vigorous use of these active 
remedies, the dry, red tongue became moist, soft, and pale — the 
pulse was diminished in frequency, and became fuller — the dry 
skin became moist, and the delirium entirely disappeared. 

These facts demonstrate conclusively that the action of the malarial 
poison in this case was that of depression and not of inflammation. 

Observation. — (x 3.) American seaman from United States revenue 
cutter; companion of the two former cases. Taken sick at the 
same time. Age 23 ; brown hair, dark eyes, florid complexion ; 
height 5 feet 7 inches ; weight 155 lbs. ; large chest, and stout 
muscular limbs. 

September 25th, 1857. "Was taken sick two days ago. His 
attack commenced with a prolonged chilly feeling, followed in the 
course of six hours with fever. Has fever now. 

B. — Calomel gr. x ; sulphate of quinia gr. v. 

26th. Medicine operated freely. Complains of pain in his head. 



386 



OBSERVATIONS ON 



Tongue coated with fur; pain upon pressure of epigastrium. 
Pulse 88. 

R. — Apply sinapism over epigastric region; and administer infu- 
sion of red pepper. 

27th. Much better; febrile excitement much less. Complains of 
slight pains in his bones and bowels. 

R. — Sulph. of quinia gr. v, every three hours, up to gr. xv ; in- 
fusion of Virginia snakeroot. 

28th. Has no fever. Give fifteen more grains of sulph. of quinia. 

29th, 11 o'clock A. M. Much better. 

7 o'clock P. M. Within the last two hours has taken a chansje 
for the worse. Intellect wandering. Complains of great pain in 
his head. Pulse 92, feeble ; respiration, 32. Eeaction of saliva 
intensely acid. The secretions of the mucous membrane of the 
mouth are almost entirely dried up, and it is with diflQculty that 
sufficient saliva is obtained to moisten the litmus paper. Tongue, 
where the fur is absent, very red — it is dry, harsh, and rough to 
the touch. Pain upon pressure of the epigastrium. Head and 
trunk hot, and extremities cool. 

R. — Sinapisms to extremities and epigastric region ; cut-cups to 
temples and back of head. 

R. — Sulphate of quinia gr. vij, every three hours, up to gr. xl. 
Administer brandy and infusion of Virginia snakeroot, freely. Diet, 
brandy and arrowroot. 

30th, 11 o'clock A. M. The mustards and stimulants have 
aroused the intellect, and rendered the dry, parched tongue moist, 
and diminished the frequency of the pulse and respiration. Pulse 
68, rather feeble; respirations, 22. Temperature of atmosphere, 
80° P.; temp, of hand, 95.5°; temp, under tongue, 97°. Skin 
slightly moist, and cool to the touch ; face much flushed ; surface 
of head cool, although from its congested, florid, red appearance, 
we would judge it to be hot. The temperature of the trunk and 
extremities is below the normal standard, notwithstanding that 
the pulse and respiration are much more rapid than in health. 
During the night he was delirious, and it was difficult to keep him 
in bed. 

The blood from the cut-cups appeared to be normal under the 
microscope, and showed no signs of inflammation. 

R. — Continue stimulants and sulph. of quinia. Diet, milk punch, 
brandy, and arrowroot. 

October 1st, 11 o'clock A. M. Continues to improve under the 



MALARIAL FEVER. 



337 



action of the stimulants and sulphate of quinia. Tongue moister 
and softer. Pulse 66, rather feeble; respirations, 20. Tempera- 
ture of atmosphere, 71.5° F. ; temp, of hand, 95°; temp, under 
tongue, 97.15°. Complains of weakness. Eested well during the 
night, and has had no pain in his head since the application of the 
cut cups. Urine orange-colored ; sp. gr. 1013. 

R.— Continue stimulants and nutritious diet. 

2d, 12 o'clock M. Tongue moist and clean, redder than normal. 
Pulse 62, regular, full and soft ; respirations, 20. Temperature of 
atmosphere, 76.5° F.; temp, of hand, 98°; temp, under tongue, 99°. 
Eeaction of saliva, decidedly acid. Urine, orange-colored and clear, 
reaction decidedly acid ; sp. gr. 1014. Amount excreted during 
the last twenty-four hours, grs. 21,210. 

R. — Continue. Full diet. 

3d. Face not so much flushed. Tongue clean, moist, soft, and 
approaching the usual color. Eespirations, 19. Temperature of 
atmosphere, 76.5° F. ; temp, of hand, 96.5°; temp, under tongue, 
98.8°. Eeaction of saliva decidedly acid. 

Color of urine, reddish- orange ; after standing several hours, let 
fall a light yellow deposit ; sp. gr. 1017. 

R. — Continue stimulants and infusion of "Virginia snakeroot tea. 

4th, 12 o'clock M. Up, and walking about the ward. Urine, 
orange colored ; the change from the acid to the alkaline reaction 
took place in the course of a few hours, and a heavy deposit was 
thrown down. Amount of urine passed during the last twenty- 
four hours, 15,270 grs.; sp. gr. 1018. Pulse 54, slow and full; 
respirations, 14. 

R. — Quassia and soda. 

5th, 11 o'clock A. M. Tongue, pulse, respiration and skin nor- 
mal. Color of urine, light orange; sp. gr. 1020 ; reaction of saliva, 
acid. 

9th. Entirely restored to health. Pulse, 43; respirations, 15. 
Temperature of atmosphere, 72° F. ; temp, of hand, 96.5° ; temp, 
under tongue, 99.75°. 

Observation. — {x 4.) Irish seaman from United States revenue 
cutter, age 19 ; height 5 feet 7^ inches ; weight 145 pounds ; light- 
brown hair, gray eyes, fair complexion. 

Oct. 4th. Was taken sick four days ago ; his attack was two days 
later than that of his companions. Has had no chill, but has suf- 
fered with pain and dizziness in the head; face flushed. Pulse, 
100; respirations, 20. Tongue coated with yellow fur, tip and 



338 



OBSERVATIONS ON 



edges red ; papillae enlarged. Ko tenderness of epigastrium. Skin 
hot. 

R. — Calomel gr. xij ; sulph. of quinia gr. vj. Mix, and admin- 
ister immediately, and follow with castor oil in four hours. As 
soon as the medicine has commenced to act, give sulph. of quinia 
gr. V every three hours up to gr. xx. 

5th. Much better. Head relieved. Skin in a profuse perspira- 
tion. Eeaction of sweat and saliva decidedly acid. Pulse, 104. 
Skin hot, but moist, and relaxed. Kespirations 24, full, thoracic. 
No tenderness upon pressure of epigastrium. Tongue redder and 
dryer than normal. Medicine operated four times. Has taken 
thirty grains of sulphate of quinia. 

R. — As soon as fever remits, give brandy and infusion of Vir- 
ginia snakeroot. 

6th. Continues to improve. Pulse, 96. Skin warm, but moist. 
Continue stimulants. 

The febrile excitement subsided and there was no return, and 
this patient was discharged a few days afterwards. 

Observations. — {x 5, 6.) Two stout, athletic young seamen, from 
the United States revenue cutter, who contracted their sickness 
simultaneously with the four seamen just mentioned. 

One suffered with a slight attack of intermittent fever, and re- 
mained in the hospital only a few days. 

The other suffered also with intermittent fever, but of a severer 
type. 

In this case, the chill was well marked, by a hot trunk and cold 
extremities, and great disturbance of the sympathetic and cerebro- 
spinal nervous systems; and in the succeeding stage of febrile 
excitement, the pulse was full and strong, the respiration accele- 
rated and the animal temperature correspondingly elevated; and in 
the intermission there was a marked subsidence of the febrile ex- 
citement. 

At first sight, the severe chill — the full, bounding pulse — the 
thoracic respiration, and the hot and parched skin, would excite 
the belief that the patient was in danger. Such an opinion would 
have been erroneous, for these phenomena signified powers of 
resistance. 

This case yielded far more readily to the action of the sulph. of 
quinia than the former cases from the cutter. 



MALARIAL FEVER. 



339 



Conclusions drawn from an Examination, Analysis, and Comparison 
OF THESE Six Cases of Malarial Fever, occurring in the Crew op 
THE United States Revenue Cutter. 

(1.) Whilst the revenue cutter was cruising about the mouth of 
the Savannah River, the crew remained healthy ; but as soon as 
they were exposed to the exhalations of the low grounds and 
marshes, they were attacked by malarial fever. This fact demon- 
strates that a special cause resided in a special locality, capable of 
producing a special disease. 

(2.) There was a remarkable uniformity in the symptoms of four 
out of the six young men from the cutter who were attacked with 
fever. 

In these cases, the malarial poison appeared to act either directly 
or secondarily, powerfully upon the nervous centres of the sympa- 
thetic and cerebro-spinal systems. 

The action of the malarial poison was depressing, rather than inflara- 
matory. Whatever diminished the forces, acted m conjunction with the 
malarial poison. . Whatever stimulated the nervous system, excited the 
action of the heart, excited the capillary circulation, excited and increased 
the chemical changes of the nutritive fluids and organs and tissues, acted 
directly antagonistic to the action and effects of the malarial poison. 

(3.) A rapid feeble pulse, rapid respiration and low temperature, 
and wandering intellect, are always dangerous symptoms, which 
signify a perversion of the functions, an interference with the 
normal chemical actions, which generate the forces, and an uncon- 
ditional surrender to the fatal poison. 

(4.) A rapid, full pulse, accelerated respiration, and a correspond- 
ing development of heat, are favorable symptoms, and signify an 
effort on the part of nature to get rid of the poison. The fever is 
not the disease — it is an effect of the action of the malarial poison upon 
the living organism, and signifies a power of resistance. 

(5.) The differences in the symptoms of these cases show that 
men living on the same small vessel, and exposed in an equal man- 
ner, will not suffer alike. The effects of the poison will depend, in 
great measure, upon the nature of their vital and physical endow- 
ments. 



840 



OBSEEVATIONS ON 



III. CONGESTIVE FEVER. 

Pernicious Fever. — Malignant Fever. 

These terms do not designate distinct diseases, but peculiar mani- 
festations of one disease, malarial fever. 

The complete prostration of the vital and physical forces ; the 
reduction of animal temperature both in the trunk and in the ex- 
tremities; the cold, clammy sweat; the rapid, feeble pulse ; the rapid 
thumping action of the heart, and the sudden intervention of the 
most alarming cerebral symptoms, may occur gradually or sud- 
denly in either intermittent or remittent fever, and may be induced 
by several distinct causes acting singly or in combination. 

Pkoposition XVII. The malarial poison may produce such 'pro- 
found alterations in the blood, and such profound impressions upon the 
sympathetic and cerebrospinal systems, and upon the fibres of the heart, 
that both the capillary circulation and the general circulation will be 
greatly deranged, the chemical changes in the capillaries and organs 
from which the nervous and muscular forces are developed, arrested, 
and the temperature of the trunk diminished. 

Proposition XVIII. The malarial poison may produce such de- 
rangements in the blood and its containing vessels, that fibrinous coagula 
will be formed in the heart and large bloodvessels, and produce suddenly 
and without previous warning, the phenomena denominated congestive. 

We have before illustrated this proposition by several striking 
cases of fibrinous concretions in the heart and large bloodvessels 
during life. 

Proposition XIX. The action of drastic purgatives or of an emetic 
or profuse bloodletting, may act in conjunction luith the malarial poison 
and induce the phenomena denominated congestive, pernicious or malig- 
nant. 

Proposition XX. As far as my observations extend, there is 
always a want of co-ordination between the actions of the circulation and 
respiration and animal temperature in congestive fever. 

The respirations are accelerated, full, and often panting and heav- 
ing, varying from 30 to 50 in the minute ; the pulse beats from 120 to 



MALAEIAL FEVER. 



841 



160, and feels like a delicate thread, or is so small that it cannot be 
counted ; the heart thumps irregularly and spasmodically against 
the walls of the chest, as in some cases of narcotic poisoning ; the 
circulation in the capillaries is arrested; the temperature of the 
trunk, notwithstanding the full and rapid respiration, sinks below 
the normal standard ; the temperature of the extremities sinks far 
below the normal standard, and the surface is covered with a cold 
clammy sweat. 

Peoposition XXI. The phenomena of congestive fever differ from 
those of the cold stage of intermittent and remittent fever in the want of 
elevation of the temperature of the trunh. 

This distinction is most important as a diagnostic and prognostic 
sign. 

Proposition XXII. The phenomena of congestive fevei" are due to 
depression of the fever ^ and not to excitation^ and should he treated ac- 
cordingly. 

The characters of the urine are not so readily determined in congestive 
fever ^ on account of the restlessness^ and often delirium of the patients. 

In some cases it is increased and of a light color. The color of 
the urine does not, as in remittent and congestive fever, correspond 
with the severity of the disease. The changes in the urine during 
congestive fever point to profound disturbances in the chemical 
changes of the capillaries. In a case which we shall relate, the 
characters of the urine were completely altered. 

The following cases will illustrate some of the phenomena and 
some of the principles of treatment of congestive fever. 

In presenting these cases, the author would again disclaim any 
attempt to present all the various phenomena of malarial fever. 

Case illustrating the Changes op the Blood in Malarial Fever, 
AND THE Disturbances of the Pulse and Respiration in Congestive 
Fever, and the Effects op Stimulants and Sulphate of Quinia. 

American seaman : native of Boston ; age 21 ; weight 150 ; height 
5 feet 10 inches; dark brown hair, brown eyes; muscular system, 
moderately well developed. This is his first trip to Savannah. 
Has been in Savannah ten days. During this time has been sleep- 
ing at night on the deck of the ship in the open air. The captain 
compelled all his men to sleep on board the ship, which was lying 
at the saw-mill, opposite the low marshy shore. Was taken sick 



342 



OBSERVATIONS ON 



four days ago. The crew consisted of eight; four of the crew slept 
on deck, and the same number in the cabin. The former are now 
sick, whilst the latter are well. 

September 26th, 1857. Tongue dryer than normal, and coated 
with yellow fur ; complexion sallow. Pain upon pressure of epi^ 
gastrium. Has some fever, and appears to be very weak. 

R. — Sinapism over epigastric region. 

R. — Sulphate of quinia gr. v, every three hours, up to gr. xv. 

27th. Has taken a change for the worse. Has been passing his 
water in bed, and is in a comatose state. When the epigastrium is 
pressed exhibits signs of pain. Pulse and respiration accelerated. 

B. — Blister over epigastric region, and sinapisms to extremities. 

R. — James' powder (Pulvis Antimonii Compositus) gr. xxij ; 
calomel gr. xij ; opium gr. ij. — Mix. Divide into twelve powders 
and administer one every two hours. 

28th, 11 o'clock A. M. The blister has aroused the nervous 
system, and the patient is restored to the use of his reason. 

B. — Continue calomel and opium. 

R. — Neutral mixture. 

7 o'clock P. M. The action of the blister has been only tempo- 
rary, and the patient is now stupid, almost comatose. Pulse, 120. 
Eespiration, 22. Pulse is so feeble that it is with difficulty counted. 
Tongue coated with yellow fur, dry and rough. The surface feels 
harsh, like the surface of a board. It is evident that the stimulant 
effect of the blister has vanished, and that the calomel is exerting 
no beneficiaf effect. 

R. — Sinapisms to extremities. 

R. — Brandy fsviij ; infusion of Virginia snakeroot foviij; sul- 
phate of quinia gr. xv. — Mix. Administer Ej every half hour. 

R. — Sulph. of quinia gr. v every three hours, up to gr. xx. 

29th, 11 o'clock A. M. Lies in a stupor, with mouth and eyes 
partially open. When aroused by shaking, answers sluggishly and 
in a few moments relapses into a stupor. Teeth coated with sordes. 
Tongue coated with black and light yellow fur, with swollen edges, 
indented by the teeth ; perfectly dry and rough. The surface of the 
tongue is transversed by several deep cracks. Surface of blister red, 
raw and dry. The serum which issued from the blister was of a 
golden color. This patient emits a disagreeable nauseous smell. 
Has taken 40 grs. of sulph. of quinia. 

R, — Continue brandy, infusion of Virginia snakeroot, and sul- 
phate of quinia. 



MALAKIAL FEVER. 



2 o'cloch P, M. Examination of Blood. 

Blood coagulated slowly. 
Serum of a deep golden color. 

Nitric acid sliowed that this color was due to the presence of bile. 
Reaction of serum, alkaline. 



Specific gravity of blood 
" " serum 



Water. 



In 1000 parts of blood 
" " serum 

(1) " " liquor sanguinis . 

(2) " " " " 

Solid Matters. 

In 1000 parts of blood 
" " serum 

(1) " " liquor sanguinis 

(2) " " « " 
In serum of 1000 parts of blood 

Fixed Saline Constituents. 
In 1000 parts of blood 
" " serum 
(2) " " liquor sanguinis . 

" " dried blood-corpuscles 
" " moist blood-corpuscles 
" " dried residue of blood 
" " " " serum 

In serum of 1000 parts of blood 



1000 parts of Blood contained — 
Water 



J Dried organic residue 
( Fixed saline constituents 



Dried blood-corpuscles 85 

Fibrin ...... 

Albumen, extractive and color- ( Dried organic residue 
ing matters . 80.033 ( Fixed saline constituents 



1000 parts of Blood contained — 



Water 



Moist blood-corpuscles 343.872 J Dried organic residue 

I Fixed saline constituents 
j' Water 
Albumen, extractive and 
Liquor sanguinis 656.128 { coloring matters 

Fixed saline constituents 
, Fibrin 

1000 parts of Moist Blood-Corpuscles contained — 

Water . . . . . . . 

Dried organic residue ..... 

Fixed saline constituents ..... 



. 1040 
. 1022 

833.449 
912.386 
910.798 
875.813 



166.551 
87.614 
89.203 

124.187 
80.033 



6.314 
6.620 
8.759 
6.595 
1.648 
37.909 
75.558 
5.747 

833.449 
84.400 
0.567 
1.450 
74.186 
5.747 

258.804 
84.400 
0.567 
574.646 

74.185 
5.747 
1.450 



752.646 
245.239 
1.648 



344 



OBSERVATIONS ON 



(1) 1000 parts of Liquor Sanguinis contained — 

Water ....... 910.797 

Albumen, extractive and coloring matters . . . 80.996 

Fixed saline constituents . . . . . 1.587 

Fibrin ....... 6.620 

(2) 1000 parts of Liquor Sanguinis contained — 

Water ....... 875.813 

Albumen, extractive and coloring matters . . 113.064 

Fixed saline constituents . . . . . 8.758 

Fibrin ....... 2.209 

7J o'clock P. M. The stimulants and sulphate of quinia have 
excited the chemical changes and aroused the nervous system, and 
the patient is now restored to the exercise of his intellect. He is 
still, however, very weak, and has a great tendency to sleep. 
Pulse, 98 ; respiration 18, full. Temperature of atmosphere, 80° F.; 
temp, of hand, 98°. Skin of head and trunk feels a little warmer 
than normal, and is slightly moist. Tongue presents the same dry, 
coated, rough appearance. Keaction of saliva decidedly acid. 

R. — Mustard to extremities. Continue brandy, infusion of Vir- 
ginia snakeroot, and sulphate of quinia. Diet : milk punch, brandy, 
and arrowroot. 

30th, 2 o'clock P. M. His intellect is clear, and there is less 
tendency to sleep, and he appears to be decidedly better. Pulse 
80, much fuller; respiratiou, 14. Temperature of atmosphere, 71° 
F.] temp, of hand, 97°. Tongue is still very dry, rough, and black 
in the centre; it appears, however, when pressed with the finger, to 
be somewhat softer. 

Urine passed this morning high colored. Urine passed during 
the night several shades lighter, and of the usual color. Reaction 
decidedly acid. Specific gravity of urine passed this morning, 
1016. Owing to the weakness of the patient, the whole amount 
was not collected. Amount of uric acid in 1000 parts of urine, 
0.59. Reaction of saliva, acid. 

R. — Continue stimulants, sulphate of quinia, and nutritious diet. 

October 1, 1 o'clock P. M. Says that he feels better, and is hun- 
gry. Pulse, 90 ; respiration, 20. Temperature of atmosphere, 78° 
F. ; temp, of hand, 98.75° ; temp, under tongue, 101°. Complexion 
very sallow. Tongue slightly moister, cleaner, and softer. 

Urine of a deep orange color, clear, and limpid ; reaction acid ; 
sp. gr., 1016. Uric acid in 1000 parts of urine, 0.659. 

2d, 1 o'clock P. M. The expression of the countenance is better, 
and the surface of the blister looks much better. Tongue still 



MALARIAL FEVER. 



34:5 



coated with dark-brown fur, but moister and softer. Tlie sordes 
around his teeth, and the disagreeable smell, are rapidly disappear- 
ing. Abdomen tumid. Pulse, 88 ; respiration, 18. Temperature 
of atmosphere, 77° F. ; temp, of hand, 102°, Was able to get up 
and walk across the ward this morning. 

R. — Continue brandy and snakeroot tea, and sulphate of quinia; 
tablespoonful every three hours. 

Urine orange colored; sp. gr., 1016. Uric acid in 1000 parts of 
urine, 0.511. Eeaction of saliva decidedly acid. As in the former 
examinations, there was scarcely sufficient saliva to moisten the 
test paper. 

3d, 1 o'clock P. M, Has apparently taken a change for the worse. 
Inclined to stupor; goes to sleep whilst conversing; countenance 
anxious and distressed. This inclination to stupor may be the 
effect of the brandy and sulphate of quinia. During the last four 
days has taken about one hundred grains of the sulphate of quinia. 

R. — Stop stimulants and sulphate of quinia. 

Pulse, 94 ; respiration, 18. Temperature of atmosphere, 77° F. ; 
temp, of hand, 102.5°. Bowels are costive. 

R. — Citrate of magnesia and soda powders. 

Urine of yesterday deposited a heavy light-yellow deposit. Urine 
just passed light orange colored, limpid; reaction acid ; sp. gr., 1006. 
Uric acid in 1000 parts of urine, 02.38. 

4:th, 2 o'clock P. M. Medicine operated slightly. Pulse, 94. 

R. — Infusion of Virginia snakeroot. 

R.—Tincture of muriate of iron ^x, three times a day. 

5th, 2 o'clock P. M. Anxious expression of countenance; bowels 
costive ; abdomen tumid. Tongue a little softer and cleaner, but 
still much drier, harder, and rougher than normal. Notwithstand- 
ing the slight improvement of his strength, there is still an almost 
complete absence of the secretions of the mucous membrane of the 
mouth. Pulse, 90; respiration, 15. Temperature of atmosphere, 
74° F.; temp, of hand, 96°; temp, under tongue, 103°. 

The temperature of the extremities is two degrees below, whilst 
the temperature of the trunk is four degrees above, that of health. 
Accompanying this loss of animal heat in the extremities, and ex- 
altation in the trunk, there is a rapid, feeble pulse, normal respira- 
tion, dry, harsh skin, dry mouth, feeble digestion, torpid bowels, 
sluggish intellect, and feeble forces^ These facts, taken in connec- 
tion with the analysis of the blood, show that the malarial poison 
has produced profound alterations in the constituents of the bloody 
23 



846 



OBSEEVATIONS ON 



interfered with tlie formation of tbe secretions, interfered with the 
chemical changes of the blood and nutritive fluids, interfered with 
the development and correlation of the physical, vital, and nervous 
forces. 

The dry, harsh tongue; the scanty, acid secretions of the mucous 
membrane of the mouth ; the torpor of the bowels; the high-colored, 
acid urine; the dry, harsh skin; the feeble circulation in the capil- 
laries of the extremities; the elevation of the temperature of the 
trunk; the loss of harmony between the actions of the circulatory 
and respiratory systems — all point to profound disturbances in the 
domain over which the sympathetic system presides. The sluggish 
intellect indicates derangement of the cerebro-spinal system. The 
feeble forces point to derangements in both the sympathetic and 
cerebro-spinal systems. 

The fact that the temperature of the extremities is but two de- 
grees below the normal standard, whilst that of the trunk is several 
degrees above the normal standard, affords evidence that the che- 
mical changes of the organs, tissues, and blood are sufficient in 
quantity to work the machinery with the accustomed vigor. But 
the machinery is not worked with the accustomed vigor; the pa- 
tient is weak, and unable to accomplish any mechanical effort at all 
corresponding to the chemical changes of the elements and solids. 
The forces are generated, but they are not properly applied, or they 
are not properly related to each other, or they are not generated in 
the right position or in the proper apparatus. If muscular force is 
generated by the chemical changes of the elements composing the 
muscular tissue, and if the nervous force is generated by the che- 
mical changes of the elements composing the nervous and muscular 
systems, if the transmission of the nervous excitement is dependent 
upon chemical changes in the elements of the nerves along which 
the excitement passes, it is evident that whatever interferes with 
those chemical changes must be attended by either an exaltation 
or depression or aberration of muscular and nervous force. If the 
colored blood-corpuscles, taken collectively, be an immense gland 
which elaborates the materials for the nutrition and development 
of the forces of the muscular and nervous systems, then their de- 
struction by the malarial poison would in great measure account 
for the disturbances in the muscular and nervous systems. 

Important questions present themselves: Do the disturbances in 
the sympathetic and cerebro-spinal systems arise from a direct 
action of the malarial poison upon one or the other of these sys- 



MALARIAL FEVER. 



347 



terns? Do the alterations in the secretions and excretions, and in 
the amount and character of the chemical changes and physical 
forces, depend upon the direct action of the malarial poison upon 
the organs, elaborating the secretions and separating the excretions, 
and preparing the materials destined to form the elements of the 
tissues and undergo those chemical changes, by which all the forces 
are generated ? Or, do the alterations of the secretions and excre- 
tions depend upon alterations of the blood, which is the great re- 
servoir of materials for chemical change and nutrition ? Or, do 
they depend upon a deficiency, or excess, or perversion, of nervous 
influence, which is supposed to influence secretion ? A correct 
solution of these problems is impossible, in the present state of 
medical science, because the ultimate facts are wanting. 

Specific gravity of urine, 1006 ; reaction alkaline after standing 
twenty-four hours. Amount of uric acid in 1000 parts of urine, 
0.078. 

R. — Stop tincture of muriate of iron immediately. At 10 
o'clock P. M. this night (twelve hours afterwards) administer calo- 
mel gr. X, followed by castor oil in four hours. If he is weakened 
by the action of the medicine, administer stimulants freely. 

6th, 1 o'clock P. M. Medicine operated four times, and has pro- 
duced great exhaustion. Tongue clean and much moister and 
softer; the moisture of the tongue, however, varies greatly. This 
morning at 10 o'clock A. M. it was moist and soft; at 12 o'clock 
M. it was almost entirely dry, and now it is moist. Pulse 100, very 
weak ; feels like the vibrations of a spider's thread. It requires 
time and care to find the pulse, and much more time and care to 
ascertain correctly its number of vibrations. It appears that I 
have made a mistake in giving the calomel and oil. His system is 
so much exhausted that it is doubtful whether it will rally. 

B. — Brandy and infusion of Virginia snakeroot ; milk punch. 

B. — Compound tincture of gentian f5j ; compound tincture of 
bark f5j. Mix, and administer three times a day in a wineglassful 
of infusion of snakeroot. 

B. — Chlorate of potassa 5 j ; water f^viij. Dissolve, and admi- 
nister during the twenty-four hours. Diet, mutton soup, boiled 
rice, brandy, arrowroot, and milk punch. 

7th, 3 o'clock P. M. Looks better. The anxious expression of 
his countenance is removed, his intellect is brighter, and his spirits 
better. Tongue softer and moister than it has been during the 
sickness. Pulse 92, watery and feeble, but stronger than yester- 



us 



OBSEEYATIONS 01^ 



day ; respirations, 13. Temperature of atmosphere, 70.5° F.; temp, 
of hand, 97°; temp, under tongue, 103°. 

B. — Continue medicine and diet. 

R. — Spirits of turpentine, 10 drops, four times a day. 

8th, 2|- o'clock P. M, Says that he feels very weak. Tongue 
moister and softer. Pulse 96, feeble and watery; respirations, 16. 
Temperature of atmosphere, 72.5° F.; temp, of hand, 97.25° ; temp, 
under tongue, 102.5°. Has not had a movement of the bowels 
since the action of the calomel. 

R, — Phosphate of soda 5iij ] water f^v. Dissolve, and administer 
in two doses. Continue tonics, stimulants, and nutritious diet. 

9th, 2 o'clock P. M. Complains of great weakness. His sallow 
complexion, anemic lips and gums, feeble pulse, and feeble forces, 
demonstrate that his feelings are founded in the effects of the 
malarial poison. Pulse, 92; respirations, 16. Temperature of at- 
mosphere, 73° F, ; temp, of hand, 86°; temp, under tongue, 103°„ 
The hand in which the thermometer was placed was carefully sur- 
rounded with the non-conducting blanket. Notwithstanding this 
favorable arrangement for the accumulation and manifestation of ani- 
mal heat, the thermometer during the period of one hour indicated a 
temperature of 86°, which is twelve degrees below the normal stand- 
ard. The temperature of his trunk, on the other hand, is four degrees 
above the normal standard and seventeen degrees above that of the 
extremities. Here we have a disturbance of the temperature ana- 
logous to that of the well-marked chill of malarial fever, and yet the 
patient does not complain of the sensation of cold, and there is no 
shivering of the muscles, and the respiration is normal in frequency, 
and the violent action of the respiratory muscles characteristic of 
a well-marked chill is absent. The feeble pulse, on the other 
hand, attended with elevation of the temperature of the trunk and 
depression of the temperature of the extremities, corresponds with 
the phenomena of a well-marked chill, and indicates deficient 
circulation of blood and arrest of chemical action in the capil- 
laries of the extremities, and, at the same time, accumulation of 
blood and increase of chemical change in the capillaries and 
bloodvessels of the large organs of the trunk. The increased heat 
of the trunk during the cold stage may arise, in part, from the 
chemical changes in the blood corpuscles, resulting in their destruc- 
tion, and in the liver, resulting in the alterations of its secretions 
and nutritive fluids. The heat thus generated by the destruction 
of the blood-corpuscles, by the alterations of the other elements of 



MALAEIAL FEVER. 



849 



the blood, and by tlie alterations of tlie secretions and nutritive 
fluids of the liver, induced by the presence of an extraneous 
poisonous body, would be generated in the wrong position, and by 
a wrong collocation, action, and reaction of elements, and would, so 
far from adding to the forces, produce derangement and interfere 
with the carefully-adjusted balance of the forces. It is a well- 
established truth in physiology that vital phenomena are mani- 
fested by matter having a- definite chemical and physical constitu- 
tion, and whatever alters the arrangement of the matter destroys 
the essential conditions of the manifestation of the vital phenomena. 
The study and investigation of man should be, not what are the 
essences of the physical, chemical, and vital forces, but what are 
the essential conditions and laws of their existence and manifesta- 
tion. 

Whilst the low temperature of the extremities, accompanied by 
a feeble rapid pulse, is a very dangerous symptom, still the condi- 
tion of the patient would be much worse if the temperature of the 
trunk corresponded with that of the extremities. A definite tem- 
perature of the trunk is absolutely essential to the maintenance of 
life in man. An elevation or depression of the temperature of the 
great organs of the trunk, of only a few degrees, is attended v/ith 
death ; because this fixed temperature is one of the essential condi- 
tions for the conduction of those chemical processes by which the 
forces are generated; and by which, under the gaidance of the vital 
principle, poisonous compounds are removed and new matter ele- 
vated into a state of force, and rendered suitable for the habitation of 
the vital principle, by the action of the forces of the sun through 
the apparatus of the vegetable kingdom, is introduced into the 
position of that chemically altered and removed; and by which 
that constitution of matter is preserved, which is indispensable for 
the existence of the vital principle, and the manifestation of vital 
phenomena, by the correlation of the chemical and physical forces, 
acting under the guidance of the vital principle, upon and through 
special apparatus. Whilst even a moderate elevation or depression 
of the temperature of the great organs of the trunk is necessarily 
attended by the generation of abnormal compounds, or by a com- 
plete arrest of the chemical and physical and nervous actions ; the 
elevation or depression, even to a great extent, of the temperature 
of the extremities is not, on the other hand, attended, by such 
serious consequences, because these parts of the body are destined 
to act as mere servants to the spiritual nature, as mere organs of 



850 



OBSEKVATIONS ON 



locoraotion and mechanical action, and not as chemical laboratories 
for tlie preparation of the nutritive elements, and of the matters 
destined for the development of the forces. ISTevertheless, as the 
forces which work the muscular system are developed by the chemi- 
cal changes of the structures of the muscles, and of the compounds 
and elements of the surrounding blood; and as the excitement and 
transmission of the nervous force to the muscular system is the 
result of the chemical changes of the elements of the nerves (and 
probably of the muscles), it is evident that a reduction or eleva- 
tion to any great extent, of the temperature of the extremities, 
must also, but in a much smaller degree, interfere with the chemi- 
cal changes going on in those muscles and with the correlation of 
the chemical, physical, and nervous forces. 

The develojjment of the mvscular and nervous forces depends upon 
the constitution of the muscular and nervous apparatus, and a free sup- 
ply of oxygen {the great agent of chemical change), and of the nutritive 
and force- generating elements of the blood. In the case before us, the 
muscular and nervous systems appear to be normal in constitution, 
whilst the blood and oxygen are wanting. 

To restore the action of the muscular and nervous systems, and 
prevent the generation of noxious compounds by the reduction of 
temperature, we must restore the circulation of blood, and the dis- 
tribution of oxygen. Acting upon these principles, I endeavored 
to arouse the circulatory, respiratory, and nervous systems, by 
sinapisms. 

Applied large mustard plasters to the extremities. 

In ten minutes after the application of the mustard, the tempera- 
ture of his extremities had risen six degrees (from 56° to 92°), and 
his pulse had become fuller, and increased eight beats (from 92 
to 100 beats). 

In half an hour after the application of the mustards, the tem- 
perature of the extremities had risen sixteen degrees, from 86° to 
102°, and the pulse had increased 12 beats to the minute. During 
these changes the respiration and the temperature of the trunk have 
remained uniform. The elevation of the temperature from 86° to 
92°, during the first ten minutes, was more rapid than the subse- 
quent elevation during the succeeding twenty minutes, from 92° to 
102°. After reaching this temperature, the thermometer indicated 
a stationary temperature both in the hand and under the tongue, 
and at 8 o'clock P. M., five hours after these observations, the pulse 



MALARIAL FEVER. 



351 



was 94; respiration 16. Temperature of atmosplaere, 70° F. ; temp, 
of hand, 102°; temp, under tongue, 103°. 

Here we see that although the frequency of the pulse has been 
reduced, and it has returned back to within two beats of what it 
was when the temperature of the hand was only 86°, still the tem- 
perature of the hand is 102°. The pulse has increased in volume, 
and hence the increased elevation of temperature is due to the 
increased circulation of blood. It is evident that the action of the 
mustard has not been evanescent. The following table will ex- 
hibit in a clear light the changes induced by the revulsives. 





Before the 


10 minutes after 


30 minutes after 


5 hours after the 




application of 


the application 


the application 


application of 




the sinapisms. 


of the sinapisms. 


of the sinapisms. 


the sinapisms. 


Pulse 


92 


100 


104 


94 


Respiration 


16 


16 


16 


16 


Temp, of atmosphere 


73° 


73° 


72° 


71° 


Temp, of hand . 


86 


92 


102 


102 


Temp, under tongue . 


103 


103 


103.2 


103 



The restoration of the circulation and chemical changes in the 
capillaries of the extremities, was attended by a subsidence of the 
twitching of the tendons, by a disappearance, in a great measure, 
of the feelings of exhaustion, by an increase of the secretions of the 
mucous membrane of the mouth, tongue, and fauces, and by an 
increase of muscular and nervous force. 

The patient says that the mustards have made him feel much 
stronger. 

In this experiment the volatile, stimulant oil of mustard, has not 
simply called forth the nervous force existing in the system, but 
has produced a permanent exaltation of the nervous and physical 
forces. 

This was accomplished by the stimulant principle of the mustard, 
and its distribution, by the bloodvessels, to all parts of the sym- 
pathetic and cerebro-spinal nervous systems. The action of the 
heart was thus increased, and the absorption and distribution of 
oxygen, promoted by an acceleration of the general and capillary 
circulation. 

Before the action of the stimulant, the chemical changes in the 
capillaries of the extremities were slow and small, because the cir- 
culation in the capillaries of the extremities was sluggish, and the 
amount of oyxgen and blood supplied to the muscles and nerves of 
the extremities, insufficient to sustain vigorous chemical changes. 

When the circulation v/as aroused, the chemical actions in the 



352 



OBSEEVATIONS ON 



extremities were correspoDdiDglj increased, because the eleraeots 
of these changes were presented in abundance, and with rapidity. 
As the muscular and nervous forces depend upon chemical change, 
the excitation of the chemical changes were necessarily attended by 
an increase of muscular and nervous force. 

Thus, the increased supply and distribution of the elements of 
chemical change, led to an increase of nervous and physical force, 
and this nervous and physical force, in turn, led to a still farther 
excitement of the machinery devoted to the absorption and dis- 
tribution of the oxygen, the great element of chemical change. 
Hence, the excitement was permanent. 

B. — Carbonate of ammonia gr. x, every four hours. 

R. — Oil of turpentine in.x, every three hours. Continue stimu- 
lants, tonics, and nutritious diet. 

10th. Much better. Temperature of the extremities corresponds 
with that of the trunk. 

Urine has a strong smell of turpentine. Amount passed during 
the last eighteen hours, 12,168 grains; sp. gr. 1014. Deep orange 
color, inclining to red ; reaction decidedly acid. Slight turbidity, 
but no deposit. 12,168 grs. of urine passed during twenty-four 
hours contained urea, 209.520 grs.; uric acid, 12.60 grs. 1000 
parts of urine contained urea, 17,212 ; uric acid, 1,035. 

4 o'clock P. M. Appetite good; tongue moist. Pulse, 100; 
much stronger than yesterday, before the application of the mus- 
tards. Eespiration, 16. Temperature of atmosphere, 69.5° F. ; 
temp, of hand, 101.° ; temp, under tongue, 102.5°. 

Urine high colored, reddish-brown ; sp. gr., 1016 ; reaction de- 
cidedly acid, clear, limpid. Amount passed during the last five 
hours, 4,562 grs. 

B. — Continue. 

11th. Continues to improve. Is able to walk about the ward. 

E. — Citrate of iron gr. ij ; sulph. of quinia-gr. iij. — Mix. Ad- 
minister three times a day. 

B. — Continue stimulants, tonics, and nutritious diet, oysters, soft 
boiled eggs, milk punch, &c. 

17th. Has continued to improve, and is now able to walk in the 
hospital grounds. He is still, however, pale, sallow, and very weak. 
Pulse 76, full and strong; perspiration, 14. Temperature of atmo- 
sphere, 67° F. ; temp, of hand, 97.25°; temp, under tongue, 100.°; 
reaction of saliva very slightly acid. During his sickness it has 
been decidedly acid. 



MALAEIAL FEVER. 



853 



I have been informed, upon reliable authority, that one week 
after the admission of this patient into the hospital, his captain 
weighed anchor and sailed for New York, The crew consisted of 
the men whom he had compelled to sleep on board the vessel, lying 
along the low, marshy shore. Several of the crew were unwell at 
the time of sailing. Before getting well out to sea, the captain and 
the whole crew were taken sick. In a few days there was not a 
man with strength to navigate the ship. Fortunately, a small 
vessel perceived their signals of distress, and towed them into 
Darien. Before reaching this port, the captain and five out of 
seven of the crew had died. There were but two remaining of 
eight, and these were extremely ill. The severity of the disease, 
in this case, resembles the accounts of African fever. From the 
report of this case, which came under our own observation, it is 
evident that any carelessness or neglect would have been attended 
by a fatal termination. Notwithstanding the administration of the 
most active tonics, and of the most nutritious diet, this patient ex- 
hibited for a great length of time the effects of the bilious remittent 
fever, in his pale, sallow, anemic countenance, pale lips and gums, 
and tottering gait. 



Case illustrating the Pulse, Respiration, and Animal Tempera- 
ture, AND THE Effects of Purgatives, in Congestive Fever. 

American seaman ; height 5 feet 9 inches ; weight 160 pounds ; 
stout, well built; large chest, brown hair, bronzed complexion, 
bilious temperament; age 45. Has been in Savannah three weeks. 
Was taken with a chill October 8, at 12 o'clock M., which lasted 
one hour, and was followed by fever, which continued, without re- 
mission, for eight hours. On the 9th inst. (the next day) had no chill. 

October 10, 1857, IJ o'clock P. M. Entered the hospital this 
morning at 10 o'clock. At 12 o'clock M. the chill came on. The 
chill was well marked; rapid, small pulse; rapid thoracic respira- 
tion; shivering, quivering muscles; high temperature of the trunk, 
and low temperature of the extremities. The chill lasted one hour 
and twenty minutes. Now (IJ o'clock P. M.) the shivering has 
ceased, and the circulation in the capillaries is more vigorous, and 
the difference between the temperature of the trunk and extremities 
less. Pulse 130, full; respiration 46, thoracic. Temperature of at- 
mosphere, 68.5° F.; temp, of hand, 100°; temp, under tongue, 106°. 
The difference of temperature between the trunk and extremities 



854 



OBSEEVATIONS ON" 



shows that the relation between the general and capillary circula- 
tions has not as yet been completely established. 

Tongue perfectly dry, and feels rough under the finger, like sand- 
paper. Those portions which are not coated by yellow fur are of a 
bright red color. Pressure over epigastric region causes some pain. 
Has pain in his chest, and a very bad cough. Says that he has 
suffered with a cough for one month, and three weeks ago "spit 
blood." Complains of "pain in his bones." Has taken no medicine. 

R. — Calomel gr. xij ; sulphate of quinia gr. vj. Mix, and admi- 
nister immediately, and follow with castor oil in four hours. 

R. — Neutral mixture. As soon as fever remits, give gr. v of the 
sulphate of quinia every three hours, up to gr. xxv. 

8 o'clock P. M. Febrile excitement is declining. Skin in a good 
perspiration. Has no pain anywhere, and is very comfortable. 

R. — Commence with sulphate of quinia immediately. 

11th, 11 o'clock A. M. Severe vomiting commenced last night 
at 11 o'clock P. M., and has continued unchecked up to 4 o'clock 
A. M., when the nurse administered a mixture of milk, lime-water, 
and acetate of morphia, which has in a great measure checked the 
vomiting. Twenty-six grains of the sulphate of quinia have been 
administered since 8 o'clock P. M. ; only eleven grains have been 
retained. Says that the calomel and oil operated pow^erfully, and 
he was upon the night-chair almost the whole night. The discharges 
appear to have been serous fluid colored with bile. Says that he has 
always been greatly affected by cathartics; even the smallest doses 
have produced violent purgation, followed by great exhaustion. I 
was not aware of this idiosyncrasy when the medicine was admi- 
nistered. Now his extremities are covered with a cold, clammy 
sweat, and he is completely exhausted. During the action of the 
medicine he was almost senseless from the great prostration conse- 
quent upon the violent purgation and vomiting. Pulse, 94; respi- 
ration, 22. Temperature of atmosphere, 71° F. ; temp, of hand, 
79°; temp, under tongue, 97°. 

The temperature of the extremities is nineteen degrees below the 
normal standard, whilst the temperature of the trunk is only two 
degrees below that of health. The pulse is accelerated thirty-four 
beats to the minute ; the respiration is but slightly accelerated. 
The temperature of the extremities and trunk does not correspond 
to the increased action of the circulation and respiration. 

This remarkable reduction of the tem.perature of the extremities 
and trunk is attended by a complete prostration of the forces. 



MALAEIAL FEVEK. 



855 



The respiration is sufficiently rapid and full to introduce large 
quantities of the great element of change — oxygen; and the action 
of the heart is sufficiently rapid, but not sufficiently powerful, to 
distribute the elements of nutrition and chemical change in the 
capillaries of the extremities. The pulse is feeble, and the circu- 
lation in the capillaries of the extremities exceedingly sluggish. 
Here we have a condition of the extremities resembling that of a 
well-marked chill. The elevation of the temperature of the trunk, 
and the shivering and quivering of the muscles, characteristic of 
the well-marked chill, however, are absent. The temperature of 
the trunk is absolutely lower than that of health, notwithstanding 
the acceleration of the respiration and circulation. This disturb- 
ance of chemical action, this disturbance of the physical forces, 
this prostration of the nervous and muscular systems, are, without 
doubt, due to the simultaneous actions of the purgative and mala- 
rial poison. Here we have an instance of vomiting and purgation 
producing such a disturbance of circulation, respiration, and che- 
mical action, and such a prostration of the muscular and nervous 
systems, that a simple case of intermittent fever is converted into 
what is ordinarily called congestive fever. 

The phenomena of this patient, during the febrile excitement, 
were such as warranted the administration of calomel. 

Administered stimulants and sulphate of quinia. His stomach 
is so irritable that it will not retain these medicines. Sinapisms 
have been applied to the extremities: bottles of hot water applied 
to feet and legs. The mustards have been very slow in their action, 
producing but little or no coloration of the skin after the lapse of 
half an hour. They remained on for three-quarters of an hour 
before the skin was decidedly reddened. After the action of the 
mustards for three-quarters of an hour, the temperature of his hand 
is 88°, and that under the tongue 97.75°. The temperature of the 
extremities has risen nine degrees, whilst that of the trunk has 
risen only three-fourths of a degree. The action of the stimulant 
principle of the mustard has been to excite the general and capil- 
lary circulation, through the sympathetic nervous system. This 
excitement has been attended by a more rapid distribution of the 
elements of nutrition and chemical change. These increased chemi- 
cal changes have been attended by an increased generation of the 
physical, muscular, and nervous forces. The increase of chemical 
change, and the increase of physical force, are attended by a rectifi- 
cation of the aberrated phenomena of the sympathetic and cerebro- 



356 



OBSEEVATIONS OIT 



spinal nervous systems. The restlessness, the feeling of complete 
exhaustion and prostration, and the vomiting, have in a great 
measure disappeared. The stomach is now able to retain stimu- 
lants and sulphate of quinia. 

R. — Continue sulphate of quinia gr. v, every three hours, np to 
gr. xl. If the stomach rejects the sulphate of quinia, administer 
ten grains by the rectum, combined with starch and tincture of 
opium, every three hours. Continue stimulants and infusion of 
Virginia snakeroot. 

Urine of a brownish-red color; sp. gr. lOl-i; reaction decidedly 
acid, even after standing forty-eight hours. When treated with 
bj^drochloric acid, the urine was changed to an almost black color. 
After standing forty-eight hours there was no deposit. Uric acid 
in 1000 parts of urine, 0.0197. It was impossible, on account of 
the severe purgation, to determine the whole amount of urine ex- 
creted. 

12th, 12 o'clock M. Says that he rested well during the night, 
and feels better, but is still very weak. Has vomited three times 
this morning. The cold, clammy feeling of his skin has disap- 
peared, and the patient appears to be decidedly better. Tongue 
red at tip, and pointed ; papilla enlarged and distinct. Pulse 100, 
much fuller and stronger than during the state of prostration. 
Eespirations 30, quick, but gentle ; does not resem.ble the full, 
labored, thoracic respiration of many cases of congestive fever. 
Temperature of atmosphere, 74° F.; temp, of hand, 100.75°; temp, 
under tongue, 101.20°. This observation demonstrates that the 
increased distribution of blood and oxygen has been attended by 
a decided elevation of temperature. Whenever there is an imper- 
fect capillary circulation, whenever there is a deficiency of the ele- 
ments of nutrition and chemical change, then will we have feeble 
forces and aberration of muscular and nervous action. The tempe- 
rature, the muscular force and the nervous force, depend absolutely 
upon the chemical changes of the elements of the living organism, 
which have been elevated into a state of force, by the action of the 
forces of the sun upon special apparatus, or rather upon a great 
laboratory, the vegetable kingdom. 

The rapidity of the chemical changes, which develop the forces 
of the machinery, depends first, upon the supply and distribution 
of materials capable of entering into the constitution of the organs, 
tissues, and apparatus; secondly, upon the supply and distribution 
of materials capable of undergoing chemical change, within and 



MALAEIAL FEVER. 



857 



aroLind the machinery, and thus generate the forces in positions 
advantageous for their application ; thirdly, upon the replacement 
of the chemically altered matter which once formed part of the 
apparatus (machinery), by new matter ; fourthly, upon the removal 
of the products of chemical change, which derange chemical action, 
first, by occupying positions in the apparatus which should be oc- 
cupied by matter in a state of force, and not by matter which has 
lost the amount of force originally received from the sun; secondly, 
by inducing chemical changes in the wrong position in parts of the 
organism, where the forces resulting from these chemical changes 
cannot be applied; and, thirdly, by a direct poisonous effect upon 
the organs, tissues, and apparatus, especially upon the nervous sys- 
tem, which keeps up a communication between all parts of the 
system, and controls, in a great measure, the distribution of the 
elements of nutrition and chemical change, by controlling the 
action of the respiratory and circulatory apparatus. 

The supply and distribution of the materials of nutrition and 
chemical change depend, first, upon the perfection and action of 
the vegetable apparatus, and secondly, upon the perfection and 
action of the animal digestive, circulatory, and respiratory appa- 
ratus, related and co-ordinated by the nervous system. 

The study of the animal kingdom, as a whole, demonstrates 
that the perfection and action of the respiratory and circulatory 
systems may be taken as an index of, not only the physical and 
chemical changes of the organized fluids and solids, but also of the 
development and perfection of the organs, and tissues, and appa- 
ratus, and of the activity and intelligence of animals. The action 
of the respiratory and circulatory apparatus, and the co-ordination of 
this action with the action and wants of the muscular and nervous 
systems, and of all these organs, and tissues, and apparatus, are 
guided by the nervous system in which a special force is generated; 
excited and guided by nervous force, but not carried on by nervous 
force, independent of chemical change. Chemical change in the 
organs and apparatus, and chemical change in the nervous system, 
is the source not only of heat, but of muscular and nervous force, 
and of all the forces generated in the animal economy. 

The generation of any force — vital^ nervous^ chemical^ or physical — in 
the animal economy^ iiidejjejident of antecedent force, luould destroy the 
great laio v2:>on ivhich the stability of the universe rests, that force is inde- 
structible — icould destroy the great law tliat action and reaction are equal. 

All the forces in the animal economy are generated by chemical 



858 



OBSEEVATIONS ON 



action. The various organs and apparatus are simply arrange- 
ments for the preparation of materials suitable for chemical change, 
and for the application of the forces generated by chemical change. 

According io this vieiv^ the action of the vital force, Wee that of the in- 
telligence, is limited to a guidance and direction of the forces with which 
the Creator has endowed all matter. The action of the vital principle 
upon matter, like that of the intelligence, does not consist, either 
in a creation of matter or in a direct movement of matter, independent of 
the forces of matter, but in the mere guidance and ajJjjlication, of the 
f.)rces of matter, so that definite form^ are developed from formless 
matter, and definite results accomplished. 

According to this view, the vital jjrinciple and the intelligence, cannot 
create force, any more than they can create mafier. Their influence is 
limited to an excitement and application of the forces of matter. 

We judge of the influence of one just as we judge of the influ- 
ence of the other. The complicated machine points to the exist- 
ence of an intelligence distinct from matter, which has so applied 
the forces of one portion of matter, that another portion has been 
moulded into definite shapes and formed into definite apparatus, 
capable of accomplishing definite results when acted upon by forces 
generated and applied in the right manner. We infer the existence 
of the intellect by the results of its application of the forces of 
matter. In precisely the same manner do we infer the existence 
of the vital principle. The vital principle directs the forces, result- 
ing from the chemical changes of one part of matter, in such a 
manner that surrounding matter is fashioned, moulded into defi- 
nite forms and apparatus, destined to accomplish definite results. 
This apparatus cannot be worked by the vital principle, independ- 
ent of chemical change, any more than a watch will run, or any 
machine will accomplish various mechanical effects, without a sup- 
ply of exterior force, or a steam engine accomplish mechanical 
effects, without the development of force by the chemical changes 
of matter, which has been elevated into a state of force (placed in 
a state capable of undergoing chemical change) by the forces of 
the sun. 

The development and structure of the vegetable kingdom, the 
development and structure and actions of the most simply con- 
structed animals, the appearance of the nervous system in the 
animal kingdom and in the foetus of the higher animals subse- 
quently to the grouping of the atoms of formless matter into 
definite forms and apparatus, before the formation of nerve-cells 
and nervous systems, demonstrate unequivocally, conclusively, 



MALARIAL FEVER. 



359 



and absolutel}^, that development, nutrition and the direction of 
the forces of one part of matter, to the fashioning of another part, 
are under the guidance of the vital principle; demonstrate une- 
quivocally, conclusively, and absolutely, that the nervous system 
itself is developed and its perfection maintained under the guidance 
of the vital principle. The nervous system is the last and best 
work of the forces of matter directed by the vital force, and is 
destined to connect toojether and influence the various orsrans and 
apparatus, and is destined to regulate secretion and excretion, and 
the consequent development of force ; and is destined to excite and 
control the actions of the dynamic muscular apparatus, not by the 
possession and emission of a peculiar force generated de novo^ but 
rather by a modification of physical force generated by the mutual 
chemical reactions of the elements of the blood and nervous system. 
The truth of this proposition is conclusively demonstrated by the 
fact that an arrest of chemical action is immediately attended by an 
arrest of nervous and muscular force. 

During the last twenty-four hours, has taken and retained 25 
grs. of the sulphate of quinia. R. — Continue stimulants. Diet, 
wine whey and arrowroot. 

Urine orange-colored ; sp. gr. 1020 ; reaction decidedly acid, and 
remained so longer than sixty hours. After standing fifty hours 
there was a slight deposit of epithelial cells, mucous corpuscles and 
cylindrical casts of the tubuli uriniferi. Amount of urine collected 
during the last twenty-four hours, 6120 grs. The patient affirms 
that this was the whole amount passed during the last twenty-four 
hours. When the urine was evaporated to the consistence of a 
syrup and treated with nitric acid, there was a powerful efferves- 
cence, and the urine assumed a dirty-brownish yellow color, and 
the nitrate of urea presented a brownish-black color, and imperfect 
crystallization. When the urine was concentrated by evaporation 
it assumed a brownish-black color. When the unconcentrated 
urine was treated with hj^drochloric acid, it assumed a dark- 
mahogany, almost black color. The solid matters of the urine 
appeared to consist principally of the coloring matters. 





6120 grains of urine, 
collected during 24 
hours, contained 


1000 parts of urine 
contained 


Fixed saline constituents 


Grains. 

41.960 
0.060 
43.8^:0 


6.822 
0.009 
7.156 



360 



OBSERVATIONS ON 



This examination of the urine shoivs that during the reduction of the 
temperature of the hody and exhaustion of the forces^ the urine was 
excreted in less amount^ and altered in quality. Here we have a demon- 
stration of the previous 2)ro2:)osiiions^ that animal temperature and mus- 
cular and nervous force are the results of chemical change^ and that the 
reduction of temperature is attended by the generation of chemical com- 
p)Ounds different from those of healthy and that the malarial poison acts 
by inducing chemical changes in the elements of the blood and organs^ 
different from the chemical changes of health. 

The fact that the chemical changes of the nutritive and force elements 
in the capillaries of the muscles and nerves and bones of the extremities 
and surface of the trunk and head were very small^ and the fact that the 
blood luas congested in the bloodvessels of the trunh^ render it probable 
that the peculiar coloring matter of the urine vjas derived from the dis- 
in tegra tedi b hod- corpusc les. 

8 o'clock P. M. Says that lie feels very weak. Has been vo- 
miting bile. Three hours ago six cut cups were applied over the 
epigastric region, without any arrest of the vomiting. Tongue 
very red at tip, and the surface is dry and rough, like sand-paper. 
The patient appears to be completely prostrated. Pulse 104. 

R. — Apply a blister, six inches by six inches, immediately over the 
epigastric region, and as soon as it blisters, if the vomiting is not ar- 
rested, remove the cuticle, and sprinkle over the raw surface one 
grain of the acetate of morphia. Stop all stimulants and adminis- 
ter internally small fragments of ice and milk and lime-water and 
acetate of morphia. 

Urine, orange colored ; sp. gr. 1016. Amount passed during 
the last eight hours, 10,160 grs. ; calculated amount of urine for 
tv/enty-four hours, 30,180 grs.; reaction decidedly acid. Here we 
have a decided increase of the urine. 

13th, 1 o'clock P. M. Says that he feels much better. Pulse 86, 
fuller and stronger ; respirations 28. Temperature of atmosphere, 
76° F.; temp, of hand, 91°; temp, under tongue, 98.5. Surface of 
the body in a profuse perspiration, which feels cold to the hand. 
The temperature of the extremities does not correspond with the 
increased circulation and respiration. The blister has drawn well, 
and the serum is of a light-yellow color, and not the golden color 
of many cases of remittent and congestive fever. The blister and 
the acetate of morphia and ice have completely arrested the obsti- 
nate and violent vomiting. 



MALAEIAL FEVER. 



861 



K. — Sulphate of quinia, gr. xv; tincture of opium tt^xx; 
starch fsiv. Mix and administer immediately as an enema, and 
repeat in the course of four hours. Diet, arrowroot and chicken 
soup. 

Amount of urine passed during the last fifteen hours 8112 grs. 
Color only a shade darker than normal ; sp. gr. 1014 ; reaction de- 
cidedly acid after standing thirty hours. No deposit after standing 
thirty hours. 





8112 grains of 
urine, excreted 
during 15 hours, 
contained 


12,979 grains of 
urine, calculated 
for 2± hours, 
contained 


1000 parts of urine 
contained 


Urea 

Uric acid . . . 
Fixed saline constituents 


Grains. 
159.080 
2.000 
16.800 


Grains. 

254.528 
3.200 
26.880 


19.594 
0.256 
2.071 



During the last three days the patient has been able to retain 
little or no nourishment, so that this is the urine of starvation. 

14th, 11 o'clock A. M. Much better ; dressed and walking about 
the ward. Pulse 72, full and strong ; respirations, 22. Tempera- 
ture of atmosphere, 78.5° F. ; temp, of hand, 96.75°; temp, under 
tongue, 98°. Skin feels normal. The cold, clammy sweat has dis- 
appeared. Tongue clean, but redder than normal. Although the 
vomiting has almost entirely disappeared, still the stomach is 
unable to retain the sulphate of quinia. 

R. — Kepeat the enema of sulph. of quinia. Diet, wine whey, soft 
boiled eggs, and arrowroot. 

15th. Continues to improve. • Pulse, 64 ; respirations, 24. Tem- 
perature of atmosphere, 74° F. ; temp, of hand, 97.75° ; temp, under 
tongue, 98.83°. Tongue still quite red, but moist and soft. The 
amount of urine has greatly increased. During the last twenty 
hours has passed 80,360 grains of light-yellow urine, which rapidly 
changes from the acid to the alkaline reaction, and lets fall a yellow 
deposit. 

Sp. gr. of tlie urine passed during tlie niglit . . . 1010 grs. 

" " this morning .... 1014 " 

Amount of uric acid passed during the last 10 hours . 28 " 

This is at the rate of sixty -seven grains of uric acid during the twenty- 
four hours. This examination confirms the statement previously made 
and substantiated in former cases^ that^ as a general rule^ the uric acid 
is either normal in amount or diminished in the active stages of malarial 
fever^ and increases during convalescence. As in the present case^ this 
24 



362 



OBSERVATIONS ON" 



increase of the uric acid rnaij iaJce place even ivhilst the patient is under 
the influence of sulphate of quinia. 

B. — Infusion of Virginia snakeroot and sulph. of quinia. Diet, 
oyster soup, wine wbey, and arrowroot. 

16th, 1 o'clock P.M. Still very weak, but continues to improve. 
Tongue not so red, moister and softer. Eeaction of saliva alkaline ; 
up to this time it has been decidedly acid. Pulse, 56 ; respirations, 
22. Temperature of atmosphere, 71.5° P. ; temp, of hand, 96°; 
temp, under tongue, 98.75°. 

Urine, light straw colored; becomes alkaline and throws down a 
light-yellow deposit, after standing a few hours. Amount passed 
during the last twenty-four hours, 29,000 grains; sp. gr. of the 
urine passed during the evening and night, 1010 ; sp. gr. of the 
urine passed this morning, 1005 ; 1000 parts of the urine passed 
this morning contained, urea 8.686 ; uric acid, a trace, a few small 
crystals; fixed saline constituents, 1.990. This examination shows 
that the elimination of uric acid has ceased in the course of a few 
hours. 

17th. Has been v/alking about the hospital grounds. Pulse, bO ; 
respirations, 26. Temperature of atmosphere, 61° F. ; temp, of hand, 
91.75°; temp, under tongue, 99°. The exercise will account for 
the acceleration of the pulse and respiration, and the free exposure 
of the hands to the cool morning air will account for the slight 
diminution of temperature, Eeaction of saliva, acid. The acidity, 
however, was not so intense as in the paroxysms. Yesterday the 
reaction of the saliva was alkaline. During the active stages of 
malarial fever the saliva, according to my observations, is always 
decidedly acid, whilst during convalescence it is generally alkaline, 
but may vary from alkaline to slightly acid. This change in the 
intensity of the acidity of the saliva corresponds, in a general way, 
with the diminution of acid in the urine. 

R. — Quassia and soda. Pull, nutritious diet. 

Amount of urine passed during the last twenty-four hours, 21,000 
grains ; urine passed during the last afternoon, evening, and night, 
orange-colored ; sp. gr., 1014. After standing a few hours the re- 
action changed from the acid to the alkaline, and a heavy, light- 
yellow deposit was thrown dow^n. Urine passed this morning of 
a light straw color ; sp. gr., 1001. 

19th. Says that he feels as w^ell as he ever did in his life. Has 
been walking about the hospital grounds. Pulse, 60; respirations, 
24. Tongue, skin, and temperature normal. Blister almost entirely 



MALARIAL FEVER. 



363 



healed. This patient had bo return of fever, and was discharged 
from the hospital a few days after this observation. 

Case illustrating the Effects of Purgatives in Malarial Fever — 
THE Relations of the Pulse, Respiration and Temperature of 
Trunk and Extremities in Congestive Fever — the Formation of 
Heart Clots in the Latter Stages of Congestive Fever. The 
Chemical Constitution of the Urine. The Chemical and Physi- 
cal and Pathological Changes of the Organs. 

Irishman, age 28, height 6 feet 7 inches, weight 140 lbs. ; dark 
brown hair, brown eyes, dark complexion. Has been in Savannah 
nine months. Engineer on steam-tug running up and down the 
Savannah River. One month ago was discharged from the steam- 
tug, and commenced "day labor," along the wharves, and at the 
saw-mill. Habits intemperate. Has been sick one week. Says that 
" three days ago he took a large dose of castor oil, which operated 
ten times. On the following day took three blue pills, and yester- 
day took another dose of castor oil, which has been operating up to 
the present time." 

August 24th, 1857, 1 o'clock P.M. Has just entered the hospital. 
Skin cool. Tongue coated with yellow fur. Pulse 120. Complains 
of great weakness. B. — Sulphate of quinia gr. xv; infusion of Vir- 
ginia snakeroot f Jxvj. — Mix. f^ij every two hours. Diet, gruel. 

25th, 12 o'clock M. Complains of great pain in his back. Sur- 
face of trunk and extremities cool. Tongue dry at tip and centre, 
and coated with yellow fur. No tenderness upon pressure of 
epigastrium. Bowels loose. 

— Stop sulph. of quinia and infusion of Virginia snakeroot. 
R. — Calomel gr. xij ; James's powder {pulvis antimonii compositus) 
gr. xxij ; mix and divide into six powders. Administer one pow- 
der every three hours. If the extremities continue cool, apply 
mustards 

26th, 12 o'clock M. During the afternoon of yesterday was 
very feeble, and at one time was almost pulseless. The nurse 
administered brandy. This induced reaction. Now skin of trunk 
and extremities cool and moist. Complexion pale, sallow; lips and 
gums very pale. Tongue coated with yellow fur, and dry at tip. 
Pulse small and weak — so feeble that it is with ditliculty that it can 
be felt at all. Pulse, 120 ; respiration, 22. Temperature of hand, 
95.5° F. 



864 



OBSERVATIONS ON 



R. — Burnt brandy and infusion of Yirginia snakeroot. Apply 
sinapisms to extremities. Diet, arrowroot and brand}^. 

8 o'clock P. M. Pulse a little stronger, but still very weak, 112. 
Surface of trunk and extremities warmer. Tongue cleaning off 
towards the tip ; the clean portion is very red, dry, and glazed. 
Has no pain, and rests quietly. Appears to be very weak. 

R. — Continue brandy and infusion of Virginia snakeroot. 

27tb, 12 o'clock M. Pulse 120, larger in volume, but still 
very feeble, and with difficulty counted ; respiration, 24. Skin 
a little warmer. Temperature of atmosphere, 87.5° F. ; temp, of 
hand, 98°; temp, under tongue, 98.5°. There is a great want of 
co-ordination between the actions of the circulatory and respiratory 
systems. Says that he is very weak. His appearance is that of 
complete exhaustion. Superior portion of tongue coated with dry 
yellow fur. A lozenge-shaped space of the surface of the tongue, 
extending for one inch from the tip to the centre, is clean and of a 
brilliant red color. Teeth coated with sordes. Hands and tongue 
tremulous. Says that he feels very weak. Has no pain anywhere, 
and lies quiet. 

R. — Stop the calomel and James's powder. R. — Sulph. of quinia 
gr. ij, every two hours, up to gr.xv. Continue brandy and infusion 
of snakeroot. 

Urine orange colored, several shades higher than in health, but 
much less highly colored than usual in severe cases of malarial 
fever. Reaction slightly acid, sp. gr. 1009, contained as usual in 
uncomjjh'cated cases of malarial fever^ no albumen^ and no grape sugar. 
Amount of urine collected during the last twenty-four hours, grs. 
16,144. The nurse states that this is the whole amount that has 
been passed. 



16.1-14 grains of urine, 
excreted in 2i hours, 
contained 



1000 parts of urine 
contained 



Grains. 



Water . 
Solid matters 
Urea 
Uric acid 



a trace, scarcely 
visible 
203.683 
24.161 



15,745.336 
398.664 
170.610 




Extractive and coloring matters 
Fixed saline constituents 



12.560 
1.496 



7 o'clock P. M. Much worse. Pulse 140, feeble; respiration 40, 
labored, panting. Extremities feel cold. Temperature of hand, 90°. 
Eestless, groans and sighs frequently. Inclined to stupor. Intel- 



MALAEIAL FEVEK. 



365 



lect sluggish ; wlien aroused appears to be sensible, but articulates 
with great difficulty. The heart appears merely to flutter; the 
sounds are so rapid and feeble that they are counted with difficulty. 
The circulation in the capillaries is sluggish and feeble. The tem- 
perature, the index of the chemical changes of the elements of the 
solids and fluids, is below the normal standard, and does not corres- 
pond with the frequency of the circulation and respiration. No 
pain -upon pressure of epigastrium. Asks for water continually, 
and complains of much thirst. The nurse has just raised him up 
to administer brandy ; he groans and tosses about the bed, and 
makes several ineffectual efforts to rise ; in a few moments he is 
quiet and apparently asleep. 

This patient died thirty minutes after this observation. 

AUTOPSY TWELVE HOURS AFTER DEATH. 

Exterior. — Body muscular, with well-developed limbs and promi- 
nent chest; trunk and limbs round, and not emaciated. Adipose 
matter not wasted. Color of muscles when the integument was 
removed, red and normal. Color of the skin of the superior parts 
of the corpse, pale, bloodless ; color of the skin of the inferior parts 
of the corpse, of a dark purple. This dark purple color gradually 
diminished towards the superior parts of the body, and appeared 
to have been due to the gradual settling of the blood in the capil- 
laries of the most dependent parts towards the close of life, when 
the general and capillary circulations were feeble. Lips and gums 
very pale, almost white. Teeth loaded with sordes. 

nead. — Dura mater unusually thick and firm, and adherent in 
several places to the arachnoid membrane. The thickening of the 
dura mater and the adhesions were of long standing, and were not 
connected with this attack of malarial fever. Bloodvessels of the 
dura mater filled with blood. 

Arachnoid membrane opalescent, pearl colored, and in many 
places adherent to the pia mater. These adhesions, like those 
between the dura mater and arachnoid membrane, were apparently 
of long standing. Between the arachnoid membrane and pia mater, 
bloody serum vv^as effused, thus imparting to these membranes (es- 
pecially the inferior portions from the gravitation of the blood) a 
red appearance. 

Bloodvessels of pia mater were filled with blood. The blood- 
vessels of those portions of the pia mater which extended into 
the ventricles of the brain, were also engorged with blood. 



866 



OBSERVATIONS ON 



The ventricles of the brain contained a small quantity of clear 
serum. 

Structure of cerebrum appeared to be softer than normal. This 
softening may have been the result of partial decomposition. 
Bloodvessels in the substance of the brain, distinct, and more en- 
gorged with blood than usual. 

Structure of cerebellum, medulla oblongata and superior portion 
of spinal cord, appeared to be normal. Bloodvessels of spinal 
cord appeared to be more congested with blood than usual. 

Chest. — Heart normal in structure; contained several clots of 
blood, which from their ragged appearance, light-yellow color, and 
freedom from colored blood-corpuscles, must have been formed 
before death. Long, fibrous coagula were found in the aorta and 
vena cava. 

Lungs. — Old adhesions in several places, numerous small tubercles 
were scattered throughout the tissues of the lungs. The tubercles did 
not appear to have suppurated. During his sickness this patient 
showed no signs, either in appearance or in action, of the existence 
of these tubercles. 

Superior portions of the lungs (leaving out of view the tubercles) 
were normal in color and density. The inferior portions were en- 
gorged with blood, and the most dependent portions were almost 
black from the great engorgement of the bloodvessels and capil- 
laries, and when cut resembled in appearance and density portions 
of liver. The accumulation of blood in the lower portions of the 
lungs was due to the action of gravity, during the feeble state of 
the circulation previous to death. The chemical changes of the 
elements of the blood and organs and tissues had been greatly di- 
minished, previously to death ; the physical forces resulting from 
these chemical changes which propelled the circulatory apparatus, 
and worked all the machinery, were correspondingly diminished^ 
and the blood gradually obeyed the physical law of gravity, which 
although constantly acting during health, was counterbalanced by 
the physical forces developed by the chemical changes of the ele- 
ments of the organism. 

Abdomen. — Liver normal in size, and of a slate color externally, 
and of a dark bronze color internally. Substance firm. When 
pressed, the dark yellow, greenish bile flowed out in small quanti- 
ties from the cut ends of the hepatic ducts. Bloodvessels of the 
liver appeared to contain more than the normal quantity of blood. 
Blood of liver dark purplish-brown, and did not change to the 



MALARIAL FEVER. 



867 



arterial hue when exposed to the action of the oxygen of the atmo- 
sphere. 

The liver contained animal starchy hut no hepatic sugar. 

Under the microscope the cells of the liver appeared normal, 
with the exception that many of them contained more oil-globules 
than usual. 

The gall-bladder was filled with bile, which was of a dark brown- 
ish-green when seen in mass, and of a gamboge color when viewed 
in thin layers. The surface of the gall-bladder was of this gamboge 
color, from the endosmosis of the bile, probably after death. 

Spleen enlarged ; color dark slate, two shades darker than the 
liver. Tissues of spleen softened ; partially disorganized. When 
the organ was pressed gently between the fingers it was evident 
that the tissues gave way. 

Mud of spleen of a dark purplish-brown color. This dark color 
was not altered, notwithstanding that it was exposed to the action 
of the atmosphere for twenty-four hours. When first removed, the 
mud of the spleen coagulated slightly. The coagnlum, however, 
possessed no consistency, and was readily dissolved. When the 
mud of the spleen (pulp and extravasated blood) was examined 
under the microscope, it was found to consist of colored and color- 
less blood-corpuscles and numerous granules of a black color. 
These black granules were frequently conglomerated together, 
forming dark flakes like the coffee-ground sediment of the black 
vomit of yellow fever. Many of the colored corpuscles appeared 
to be swollen. The colorless corpuscles appeared to be more 
numerous than normal. 

Alimentary Canal. — Stomach contained no fluid or gas; blood- 
vessels upon the exterior filled with blood. Mucous membrane of 
stomach of a dark purplish color. The color of the mucous mem- 
brane was not uniform ; it was much deeper in some spots than in 
others, thus presenting a mottled appearance. 

The compound muciparous follicles (Brunner's glands) of the 
stomach and duodenum were prominent and enlarged. 

Bloodvessels of the superior and inferior portions of the intestinal 
canal appeared to be more engorged with blood than those of the 
middle portions. The mucous membrane of the small intestine was 
covered by a layer of mucus and fecal matter, colored yellow by 
the bile. 

The solitary glands in the inferior portion of the ileum, and 



363 



OBSEEVATIONS ON 



especially in the region of the ileo-c^cal valve, were enlarged and 
distinct. 

The glands of Peyer were distinct, but not enlarged or inflamed. 

The serous membrane of the intestines bore the marks of an old 
inflammation. The serous membrane was thickened, and organized 
bands of coagulable lymph in many places bound the large and 
small intestines together and to the walls of the abdominal cavity. 
This inflammation had nothing whatever to do with the present 
attack. 

Kidneys normal in size and structure. Blood had settled in the 
vessels and capillaries of the inferior dependent portions. Color of 
superior portions of kidneys normal; color of inferior dependent portions 
almost as dark as the slate-colored liver. 

The bloodvessels and capillaries of the cellular tissue of the pos- 
terior dependent walls of the abdominal cavity were engorged with 
blood, whilst those of the upper anterior and lateral walls were 
almost devoid of blood. This was due to the action of gravity 
upon the enfeebled circulation. 

The facts which we have presented show that the capillary cir- 
culation had been greatly enfeebled in every organ and tissue 
previous to death, and the blood necessarily accumulated in the 
most dependent bloodvessels and capillaries. This view is farther 
confirmed by the fact that the vena cava contained but little blood. 

The bladder contained 5000 grains of light-colored urine. 

Keaction acid; sp. gr,, 1008.7. 

After standing forty-eight hours no deposit was thrown down. 
This was also true of the former specimen of urine. 





5000 grains of urine 


1000 parts of urine 




contained 


contained 




Grains. 








972.628 




136.860 


27.372 




38.945 


7.789 




0.240 


0.048 


Extractive and coloring matters 


88.005 


17.601 


Fixed saline constituents 


9.120 


1.824 



CONCLUSIONS. 

(1.) The slate-colored liver, the dark greenish-brown bile, the 
absence of grape sugar and the presence of animal starch in the 
liver — the slate-colored, enlarged, engorged, softened spleen — de- 
monstrated that this was a case of malarial fever. 



MALAKIAL FEVEK. 



369 



(2.) The rapid and feeble action of the heart; the rapid and feeble 
pulse ; the depressed temperature of the trunk and extremities ; 
the dry, red tongue ; the complete exhaustion of the muscular and 
nervous force; the acid, light-colored urine; the feeble general and 
capillary circulation, gradually overcome by the action of gravity; 
the gradual settling of the blood previous to death in the blood- 
vessels of the most dependent parts of all the organs and tissues; 
the alterations of the blood-corpuscles of the liver and spleen ; the 
alterations in the color and constitution of the bile; the destruction 
of the special ferment in the blood which converted the animal 
starch into grape sugar — demonstrated that the malarial poison 
had not only interfered with the action of the cerebro-spinal sys- 
tem, but had also affected the sympathetic system, and produced 
profound alterations in the structure of the nutritive fluids, and cor- 
respondingly interfered with the chemical changes, the development 
of the forces, and the formation of the secretions and excretions. 

(3.) The rapid exhaustion of the forces was, without doubt, due, 
in a great measure, to the severe purgation to which this patient 
had been subjected previous to his entrance into the hospital, and 
to his previous intemperate habits, and to the presence of tubercles 
in the lungs. The administration of large doses of purgative medi- 
cines (castor oil and blue pill), without any sulphate of quinia, and 
without any stimulants, converted an ordinary case of malarial 
fever into a congestive malarial fever. The term congestive, as 
applied to this case, means nothing more than a state of exhaustion, 
inability to resist the action of the malarial poison, inability to 
react. 

(4.) The plan of treatment in this case was correct in principle, 
but radically deficient in energy. Stimulants were administered, 
but not in sufficient quantities. Sinapisms were used, but not often 
enough, nor large enough, nor long enough. Sulphate of quinia 
was administered, but too infrequently and in too small doses to be 
efficient, and much valuable time was wasted. This case demanded 
prompt and vigorous action. Large doses of the sulphate of quinia 
and the most diffusible and powerful stimulants should have been 
promptly and frequently administered, and the extremities should 
have been repeatedly covered with sinapisms. 



370 



OBSEEVATIONS ON 



Case illustrating the Action of Purgatives in Malarial Fearer. 
Principles which should govern the Administration of Purga- 
tives in Malarial Fever. 

English seaman ; height 5 feet 7 J inches ; weight 145 pounds ; 
black hair, brown eyes, dark complexion; age 46; well-built, mus- 
cular man. First trip to Savannah. Has been in this port three 
weeks, and during this time has slept on board ship. 

October 13, 1857, 11 o'clock A.M. Says that he was taken sick 
two days ago, with pain in his head and bones, and loss of appetite. 
Last night, between 8 and 9 o'clock P. M., had a chill, which lasted 
for one hour, and was succeeded by fever, which remitted this morn- 
ing with a profuse perspiration. Tongue pale and clean. Bowels 
have not been moved for three days. 

R. — Calomel gr. xij ; sulphate of quinia gr. vj. — Mix. Admi- 
nister immediately, and follow with castor oil in four hours. As 
soon as the medicine has operated once, give gr. v of the sulphate 
of quinia every three hours, up to gr. xx. 

13th, 11 o'clock A.M. The medicine operated freely. Has taken 
twenty-six grains of the sulphate of quinia. The patient is weak 
and stupid. Pays no attention to inquiries, even when the voice 
is greatly elevated. When aroused by violent shaking, answers 
incoherently, and in a few moments relapses into a stupor. Great 
tenderness upon pressure of epigastric region ; pressure here arouses 
him, and he cries out. Pulse 120, very feeble; so feeble that it is 
with difficulty that it can be felt, and with still greater difficulty 
that its number of beats to the minute can be ascertained ; respira- 
tion 40, thoracic, labored. Tongue coated with yellow fur, moist, 
and soft. Skin warm and moist; in a perspiration. 

Administered f^ij of a mixture of equal parts of brandy and 
infusion of Virginia snakeroot. As soon as the fluids entered the 
stomach they were ejected again, with great violence, over the table 
and the neighboring bed. The brandy and infusion of snakeroot 
had mingled with the contents of the stomach, and were of a green 
color. The act of vomiting was performed, apparently, without 
any effort. There was no retching previous to the ejection of the 
fluids. They came up in a stream. 

R. — Mustards to extremities and interior surface of thighs, and 
a blister six inches by five over the epigastric region. 

B. — Lime-water f5ij; milk f^ij; solution of acetate of morphia 



MALAKIAL FEVEK. 



871 



f5j. — Mix. Aclraioister immediately, and repeat every half hour 
until his stomach is settled. As soon as the stomach will retain 
this mixture, administer sulphate of quinia, brandy, and infusion 
of Virginia snakeroot, freely. 

8 o'clock P. M. More sensible than this morning, but weak and 
restless. Breathing not so accelerated and labored. Pulse 120, 
still very feeble. Blister is drawling. 

R. — Sulphate of quinia gr. v every three hours, up to gr. xxx. 

Tf his stomach rejects this, give the following injection: — 

B. — Sulphate of quinia gr. x; starch f^ij; tincture of opium 
^n,xv. — Mix. Eepeat every three hours until forty grains of the 
sulphate of quinia have been administered. Administer brandy, 
infusion of Virginia snakeroot, and spirit of mindererus, freely. 

14th, 11 o'clock A. M. Says that he is much better. Intellect 
clear ; answers coherently. He is much more quiet. Blister has 
drawn well ; serum golden colored. Pulse 96, much stronger and 
more regular, but still feeble; respiration, 24. Tongue soft and 
moist; superior portion coated with white fur. Under the action 
of sulphate of quinia and stimulants the pulse has diminished in 
frequency and increased in volume, and the respiration has dimi- 
nished in frequency, and the spasmodic actions of the respiratory 
muscles have ceased, and the nervous system has been aroused, and 
the dull intellect has resumed its normal actions. If stimulants had 
been withheld, it is highly prohahle that this patient ivould have died 
from complete exhaustion of the nervous and vital powers, conse- 
quent upon the action of the malarial poison, either directly upon 
the nervous ganglia of the sympathetic system presiding over the 
respiration and circulation ; or by such changes in the elements of 
the blood (especially of the blood-corpuscles) as resulted in the 
perversion of the nutritive elements of the nervous ganglia, or in 
the generation of compounds in the blood and in the secretions of 
the liver, spleen, and alimentary canal, which acted as poisons upon 
the sympathetic and cerebro-spinal nervous systems, or by the 
simultaneous action of the poison in all these different ways. 

R. — Continue brandy and infusion of Virginia snakeroot. Stop 
sulphate of quinia. Diet, milk punch and arrowroot. 

15th, 11 o'clock A. M. Continues to improve. Has no pain 
anywhere. Tip of tongue clean and redder than normal ; posterior 
portion coated with patches of black fur. Pulse, 88 ; respiration, 
16. Temperature of trunk normal; reaction of saliva neutral. 
R. — Continue stimulants and nutritious diet. 



372 



OBSERVATIONS ON 



8 o'clock p. M. Continues to improve. Up to the present time, 
owing to the action of the medicine, the congestive chill, delirium 
and weakness, it has been impossible to obtain any urine for 
analysis. Urine passed this afternoon orange colored. Amount 
passed during the last twenty-four hours, 5050 grs.; calculated 
amount for twenty-four hours, 15,510; sp. gr., 1010; reaction acid. 





5050 grains of 
urine, excreted 
during 8 hours, 
contained 


15,150 gi'ains of 
urine, calculated 
for 24 hours, 
contained 


1000 parts of urine 
contained 


Urea 

Uric acid .... 
Fixed saline constituents 


Grains. 
129.495 
3.250 
8.500 


Grains. 

338.395 
9.750 
25.500 


25.642 
0.643 
1.683 



16th, 11 o'clock A. M. Continues to improve. Tongue soft, 
moist and normal in appearance. Eeaction of saliva decidedly 
acid. His appetite is good. Pulse, 81; respiration, 15. Urine 
passed during the night, of a deep orange color; sp. gr. 1014. 
Eeaction when first voided acid, after the lapse of fifteen hours 
slightly alkaline. Simultaneously with the change from acid to 
alkaline, there was the formation of numerous well formed pris- 
matic crystals of triple phosphate. When the urine was held in 
the sunlight, these crystals sparkled like particles of silver. 

1000 parts of Urine contained — 

Urea ....... 24.761 

Uric acid 0.029 

Fixed saline constituents ..... 1.773 

B. — Continue brandy and infusion of Yirginia snakeroot and 
nutritious diet. 

R. — Quassia and soda. 

17th. Greatly improved; dressed and walking about the hospital 
yard. Pulse, 72. Tongue, skin, respiration and temperature, nor- 
mal. Complains of nothing but weakness. 

The captain of the vessel to which this seaman belonged has 
just informed me that his crew consisted of eight men and a woman 
(the cook). Four of the men and the cook slept aboard the ship 
lying in the Savannah Eiver. Every one was taken sick with 
malarial fever, and entered the hospital. Of the four seamen who 
slept ashore, two were taken sick; their attacks, however, were 
much lighter than those who slept on board the ship. 



MALARIAL FEYER. 



873 



conclusions. 

Principles which should govern the Administration of Purgatives 
IN Malarial Fever. 

(1.) This case illustrates the necessity of watching the action of 
purgatives in malarial fever. 

I have treated numerous cases of malarial fever, both with and 
without purgatives, and from a careful comparison of the results of 
the different modes of treatment, have found that the disease yields 
much sooner to the action of the sulphate of quinia, after the action 
of a purgative. The purgative which I have almost invariably 
employed at the commencement of the disease, is calomel. . It was 
administered in doses from vij to xij grains, conjoined with from v 
to vij grains of the sulphate of quinia. The liver and portal circu- 
lation, and perhaps the spleen to a certain extent, are relieved by 
the action of the purgative, and the sulphate of quinia is absorbed 
much more readily and rapidly. The sulphate of quinia appears 
to affect the head much less after the action of a purgative. I have 
frequently observed, that in both intermittent and remittent fever, 
the action of calomel on the alimentary canal, and liver, especially 
when accompanied by, and followed with large doses of sulphate 
of quinia, was attended with relaxation of the hard dry skin, in- 
crease of the secretions of the dry red mucous membrane of the 
tongue and mouth, and relief of the cerebral symptoms. 

The purgative hy no means cures the disease. The purgative simply 
excites the alimentary canal to eliminate and throw off offending 
matters, and relieves the congestion of important organs, and thus 
equalizes the circulation, promotes secretion, and secondarily re- 
lieves some of the nervous phenomena. If the patient was left thus 
without farther treatment, the malarial poison would still continue 
its work unchecked. The purgative "prepares the system" for the 
action of sulphate of quinia and stimulants. 

In the administration of purgatives in malarial fever, however, 
the practitioner should always bear in mind the important fact, 
that there are certain cases, as the present one, and others already 
recorded, in which purgatives will produce in conjunction with the 
malarial poison, sudden and dangerous depression of the system. 
It is important that the practitioner should study carefully the 
indications for and against the employment of purgatives. 

I will state my experience in the following propositions : — 



374 



OBSERVATIONS ON" 



(a.) Whenever there is a full, rapid, hounding pulse, rapid respira- 
tion and corresponding chemical change and development of heat; whether 
the tongue he red or pale, dry or moist; whether the shin he dry or moist; 
whether the intellect he clear or clouded, a moderate dose of calomel, espe- 
cially if it he mixed with sulphate of quinia, will prove highly heneficial, 
and expedite the suhsequent action of the sulphate of quinia, and hasten 
the termination of the disease. 

(6.) Whenever there is a feehle, rapid pulse, and rapid, thoracic respi- 
ration, and no corresponding elevation of temperature {in many cases a 
great depression), ivith or without a dry, red tongue, with a dry, harsh 
skin, or with a cold clammy sweat, with or without cerehral disturhance, 
with or without restlessness, purgatives should he rigidly avoided. 

(c.) Whenever there is a marked luant of co-ordination hetween the 
actions of the circulatory and respiratory systems, and the chemical 
changes and consequent development of the physical and nervous forces, 
purgatives should he avoided. 

((/.) If purgatives be administered, without being followed with 
sulphate of quinia, they act in conjunction with the malarial poison, 
by diminishing the amount of the blood and depressing the forces. 

(e.) If purgatives be administered repeatedly with or without 
sulphate of quinia, they may convert a case of simple intermittent 
or remittent fever, into one of congestive fever. 

(/.) The best purgative is calomel. 

{g) The proper time for the administration of the purgative, is 
at the commencement of the disease. 

(A.) x\fter the free evacuation of the intestinal canal, the purga- 
tive should not be repeated. 

{%) The action of the purgative in all cases of malarial fever 
should be carefully watched, and if there is any depression of the 
forces, stimulants and sulphate of quinia should be immediately 
and liberally administered, and sinapisms or blisters applied. Car- 
bonate of ammonia is one of the most valuable stimulants in these 
cases; sulphate of quinia should always be combined with the 
purgative. 

(2.) The tongue did not present the dry, harsh, red appearance, 
so common in these severe cases. 

I have observed that the dry, red tongue, is more common in 
the first than in the second or succeeding attacks of malarial fever. 
This patient stated that he had a severe attack of fever, several 
years ago, on the coast of Africa, at the mouth of the river 
Sierra Leone. Says that this attack was similar to the present 



MALAEIAL FEVEK. 



375 



one. lie was out of liis head, and no hopes were entertained of 
his recovery. The fever was of a malignant type. The crew of the 
ship was composed of eight strong active men, and out of this num- 
ber, six died. It is highly probable that the disease was malarial 
fever. It is reasonable to suppose that this severe attack of malig- 
nant malarial fever left a permanent impress upon his constitution, 
and influenced the symptoms of the present attack. 

In attempting to account for the different manifestations of dis- 
ease, we have not, in the present state of science, access to all the 
data, such as original constitution, previous habits and previous 
diseases. 

It is probable that the course of severe diseases is always modi- 
fied by the constitution, diet, occupation, and previous habits, 
whether virtuous or vicious, temperate or intemperate, and by pre- 
vious diseases, and by the relations of the individual and his an- 
cestors to the climate and soil. We know that in a body of strong 
healthy men, exposed to precisely the same sources of malarial 
disease, we may have manifestations of disease, from a slight febrile 
excitement, scarcely deviating from the condition of health, down 
to the most malignant type, commonly called congestive fever. 

If all have been alike exposed upon the same small ship, to the 
same poison, whence this difference ? 

The difficulty and complexity of this problem may be compre- 
hended when we state that, amono^st other thins^s, its solution 
w^ould demand a knowledge of the previous history of the physical, 
chemical, physiological, and moral influences of soil and climate, 
and disease upon the ancestors, and even upon the races; would 
demand a knowledge of all hereditary tendencies, peculiarities of 
temperament and idiosyncrasy ; would demand a knowledge of 
the relative activity and perfection of the individual organs and 
apparatus, and of the relations of these to each other ; would de- 
mand a knowledge of the relations of the vital force to the matter 
of each organ, and tissue, and apparatus, and to the morbific agent 
or agents ; would demand a knowledge of the action and reaction 
of the morbific matter upon the different forms of organized struc- 
ture, and the consequent derangement of the physical, nervous, in- 
tellectual, and moral phenomena ; would demand a knowledge of 
the relations of chemical action to the development of the physical 
and nervous forces, and the action of the intellectual and moral facul- 
ties; would demand a knowledge of the correlations of the physical, 
vital, nervous, intellectual, and moral phenomena; would dem^and 



876 



OBSEUVATIONS ON 



a knowledge of the relations between pbysiological phenomena and 
the phenomena of the exterior universe. Every candid man will 
admit that the solution of such a problem is impossible at the pre- 
sent time, because the facts are wanting. And thej will be long 
wanting, owing to the extreme complexity of the phenomena. 

A thorough knowledge of pathological 2^henomena^ necessarily includes 
a 'knowledge of the relations of all the phenor)iena of the universe. The 
dignity and glory of a science should certainly depend upon the 
multitude and complexity of its phenomena. "We hope, however, 
that the day will come when the science of medicine shall be founded 
upon the immovable basis of inductive philosophy, and the world 
be compelled to recognize the truth, that the solution of the pro- 
blems of medicine requires a higher exercise of the reasoning facul- 
ties than the solution of the most complicated and difficult pro- 
blems in physical and chemical science ; a higher exercise of the 
reasoning faculties than the solution of even the grandest problems 
of astronomy. 

Case of Congestive Fever, illustrating the Effects of the Mala- 
rial Poison upon the Nervous System, Muscular System and 
Organs; the Physical and Chemical Changes of the Urine; and 
also the Formation of Heart-Clots. Treatment of Congestive 
Fever. 

Ohservation. — German ; age, 40 ; height, 5 feet 9 inches ; weight, 
150 lbs.; black hair, black eyes; sallow complexion; occupation, 
bar-keeper. 

October 16, 1857, 8 o'clock P.M. Has just entered the hospital. 
Is unable to give coherent answers, and is either stupid or unable 
to speak the English language. His companion states that this 
patient has been in Savannah for two months, and has been sick 
with chill and fever for two weeks. He is exceedingly weak, and 
his intellect wanders. Pulse 112, rather feeble. 

R.— Calomel gr. xij ; sulphate of quinia gr. vj. — Mix. Ad- 
minister and follow with castor oil in four hours. 

R. — As soon as the calomel has acted once, commence with 
sulph. of quinia, gr. v every three hours up to gr. xx. 

17th, 11 A. M. When I saw this patient last night, I supposed 
that this stupidity and difficulty of speech were due, in a great 
measure, to the fact that he was a foreigner, imperfectly acquainted 
with our language. A careful examination this morning, however. 



MALARIAL FEVER. 



377 



shows that the difficulty of speech and torpor of intellect are de- 
pendent upon the effects of the malarial poison (either directly or 
indirectly) upon the brain. When questioned, endeavors to con- 
verse ; commences sentences, but is unable to finish them. Pulse 
124, very feeble; respiration, 28; tongue, dry, hard, and rough, 
and coated with dry, brownish-yellow fur. The tongue feels very 
hard and rough. There is not moisture enough in his mouth to 
produce any sensible effect upon a bit of paper pressed against the 
tongue. Skin warm and dry. The temperature of the skin cor- 
responds with the feebleness of the pulse, but not to its frequency, 
and not to the frequency of respiration. Says that he feels well. 

B. — Mustards to extremities. Cut cups to temples and back of 
neck. R. — Administer freely, brandy, infasion of Virginia snake- 
root, spirit of mindererus, and sulphate of quinia. 

8 o'clock P. M. The cut cups and mustards aroused him for a 
short time, but he has relapsed into the state of partial stupor, in 
spite of the action of the sulphate of quinia and stimulants. 

R. — Continue stimulants, infusion of Virginia snakeroot, and 
sulphate of quinia. 

18th, 11 o'clock A. M. No improvement. Tongue very red at 
edges and tip, which are free from fur. Surface of tongue coated 
with dry, yellow fur, and presents the same dry, rough feeling and 
appearance. Teeth coated with sordes. The pulse is so rapid and 
feeble that it is almost impossible to ascertain accurately its num- 
ber of beats. It feels like the delicate pulsations of a minute 
capillary filled with water. The pulsations cease, as soon as the 
slightest pressure is made. Pulse, 155 to minute. The heart 
merely thumps (flutters). The two sounds are merged into one, and 
cannot be distinguished. The sounds of the heart correspond in 
number to the beating of the pulse, 155 to minute. The corres- 
pondence of the two was examined not only by separate calculatioUj 
but also by applying the ear over the region of the chest, and the 
hand over the pulse at the wrist. Kespiration 34, spasmodic. 
Skin covered with cold, clammy sweat. Extremities are at least 
20 degrees below the normal standard. Trunk and head feel cold ; 
their temperature several degrees below the normal standard. 

The action of the heart is feeble ; the capillary circulation is 
exceedingly feeble and sluggish. The distribution of the nutritive 
and force elements is correspondingly retarded, and, as a necessary 
consequence, the chemical changes are diminished and altered both 
in quantity and kind, 
25 



378 



OBSERYATIOXS OX 



The patient is very restless, tosses about the bed, and is with 
the greatest difficulty retained in bed. Passes his water and feces 
in bed. Intellect wandering ; talks incoherently. Says that he is 
perfectly well, and wishes nothing but water. When aroused, his 
eye looks bright, and there is no expression of pain or uneasiness 
upon his countenance. 

During the last thirty-six hours has taken fifty grains of the 
sulphate of quinia, together with large quantities of stimulants. 
Mustards have been frequently applied. The efl'ect of these reme- 
dies appears to be only palliative. They have produced no per- 
manent beneficial effect. Whenever the mustards and stimulants 
were withheld, the forces decreased rapidly, and the patient would 
relapse almost into a profound stupor. The action of the mustards 
w^as very slow on account of the sluggish capillary circulation. 

R. — Continue stimulants. Apply bottles of hot water to the ex- 
tremities. Administer 10 grains of the sulphate of quinia imme- 
diately, and repeat every three hours. R. — Blister to back of neck. 

9 J o'clock P. M. The mustards and stimulants aroused him, and 
at 6 o'clock P. M. this evening his pulse was fuller, his tongue was 
moister, his intellect clearer, and the restlessness had, in a great 
measure, disappeared. The patient, during the momentary absence 
of the nurse, got out of bed and attempted to walk across the floor, 
to the bucket of water at the other end of the ward. He had not 
proceeded more than five steps, before he fell upon the floor, com- 
pletely exhausted. Almost immediately his pulse became more 
frequent and feeble, in fact, almost entirely disappeared, and his 
extremities became much colder. Mustards were again applied, 
and stimulants administered. Under the action of these, his cir- 
culation, both general and capillary, was increased somewhat in 
force, and his exhausted forces revived. 

Kow his pulse is 135, and his respiration 32. The sordes on the 
teeth, which were this morning perfectly dry, are moister; the tongue 
is moister; the pulse is fuller (although still exceedingly feeble and 
flickering), than it was this morning. 

There is an unnatural brilliancy about his eye, and excitement 
about his intellect. He converses freely for the first time ; says 
that he feels perfectly well, and wishes to go immediately home to 
the hotel and take the place of the bar-keeper, who he says is sick. 
Complains bitterly of being confined to bed, when nothing is the 
matter with him, and he feels as strong and as well as he ever did | 
in his life. Has been quarrelling with the nurse, and threatens i 



MALARIAL FEVER. 



879 



vengeance, because he confines him to bed and will not allow him 
to dress himself and go and drink freely of water. Complains 
greatly of thirst ; keeps his eye fixed on the vessel containing 
water, notwithstanding that he is liberally supplied. Has vomited 
several times. The blister is acting, and the serum is of a golden 
color. Has taken 30 grs. of the sulphate of quinia since 11 o'clock 
this morning. 

Has just passed urine. It is perfectly clear, and amber-colored. 
The color of the urine is in striking contrast to that of patients ivho are 
able to resist the effects of the malarial poison to the extent of the produc- 
tion of the febrile exciterjient. When the constitution is able to cope vjith 
the malarial poison^ v:e have a rapid pulse^ rapid respiration^ high tem- 
perature^ rapid chemical change^ and high-colored concentrated urine. 
Specific gravity of urine, 1015.3. Eeaction strongly acid. The 
urine changed the litmus blue paper to as bright a red as a strong 
mineral acid. The rapidity of the change also corresponded to the 
action of a powerful acid. After standing 70 hours the reaction 
was still decidedly acid, and there was no deposit of any kind. 
When the urine was evaporated, the residue w^as a dark reddish- 
brown viscous mass, resembling tar. After prolonged, tedious, 
and careful evaporation, it was found to be impossible to reduce 
it to a solid state. When the urine, concentrated to the consist- 
ence of a syrup, was treated with nitric acid;- there was a slight 
effervescence, and a few crystals appeared. These crystals were 
transparent, and resembled rather crystals of saltpetre than the 
silvery crystals of nitrate of urea. After standing for a short 
time these crystals disappeared, and did not again appear even 
when the fluid was concentrated by evaporation. If these crystals 
were nitrate of urea, the whole amount existing in 1000 grs. of 
urine must have been less than 2 grs. In a fluidounce of urine 
not more than a trace of uric acid could be detected after careful 
examination. Under the microscope a few small crystals could be 
detected which were invisible to the naked eye. 

1000 parts of Urine contained — 



Solid matters ..... 


. 34.482 


VTater ...... 


. 965.518 


Urea ...... 


a trace 


Uric acid ..... 


a trace 


Extractive, coloring, and organic matters 


. 24.805 


Fixed saline constituents, principally phosphates 


9.655 



The fixed saline constituents were principally the phosphates. 



880 



OBSEKVATIONS ON 



A short time after this observation the excitement and restless- 
ness of this patient disappeared, and he went into a profound sleep 
and died at 1 o'clock A. M. 

AUTOPSY TWELVE HOURS AFTER DEATH. 

Exterior. — Limbs and trunks round and full, and apparently in 
full flesh. The skin over the whole surface except the face pre- 
sented a fair white color. There was no settling of the blood in 
the capillaries of the most dependent portions of the skin producing 
the mottled appearance previously noticed. This may be due to 
the fact that the patient was under the action of stimulants at the 
time of death. 

Head. — Dura mater^ normal. Arachnoid membrane opalescent 
(pearl colored) in many spots. Serum was effused between the 
arachnoid membrane and pia mater. Bloodvessels of pia mater, 
filled with blood. Substance of brain was firm, and was altered 
neither in consistency nor in appearance. Bloodvessels of the 
substance of the brain not more distinct than normal. Yentricles 
of the brain were almost entirely filled with light-yellow serum. 
Light-yellow serum was effused around the medulla oblongata, and 
superior portion of spinal cord. The effused serum appeared to 
fill completely the spaces between the spinal cord and its membranes 
and the surrounding vertebral cavity. When the medulla oblon- 
gata and superior portion of the spinal cord were removed, the 
serum flowed in (the shoulders being slightly depressed) and filled 
the vertebral canal. 

Chest. — Lungs normal. Bloodvessels of the dependent portions 
engorged with blood. 

Heart normal in size and structure. The ventricles and auricles 
contained clots. Portions of these clots were free from colored 
corpuscles and presented the yellow color of whipped fibrin. Sur- 
rounding, and attached to these, were ordinary coagula of blood. 
The vena cava, and all the large venous trunks in the abdominal 
cavity, were filled with dark, almost black coagulated blood. 

Abdominal Cavity. — Liver^ somewhat enlarged ; and presented a 
singular mottled appearance. At a distance it presented a light 
bronzed color. Upon nearer inspection, the lobules were found to 
be distinct, elevated, and of a light-bronze color, whilst the spaces 
between the lobules inclined to a slate color. There were several 
spots varying from two inches to half an inch in diameter of a uni- 



MALARIAL FEVER. 



381 



form slate color. The structure of the liver was unusually firm; it 
required considerable force to tear it asunder; it cut toughly under 
the knife, and the lobules started out from the cut surface as if 
they had been bound down. The fibrous capsule surrounding the 
exterior of the liver and forming a sheath for the large vessels 
lying in the portal canals was thickened, and the individual lobules 
of the liver were surrounded with fibrous tissue. These facts, 
"which were demonstrated not only by the touch and naked eye, but 
also by the microscope, show that this liver was in a cirrhosed con- 
dition. Cirrhosis of the liver in this case was not caused by the 
action of the malarial poison, but in all probability, by the habitual 
use of ardent spirits. 

This patient was a barkeeper. Men in this occupation are, as a 
general rule, addicted to the free use of ardent spirits. The liquors 
drank in this country at the hotels and bar-rooms contain niuch 
alcohol, which acts upon the secreting structures of the liver and 
upon the bloodvessels, and excites adhesive inflammation in the 
areolar tissue of the small twigs of the portal vein, and in the areo- 
lar tissue of the portal canals, by which serous fluid and coagulable 
lymph are thrown out. Under the microscope, the substance of 
the liver contained many dark looking masses, resembling the 
altered blood-corpuscles of the spleen, and the black granules and 
flakes of black vomit. These dark masses were not sufficiently 
numerous to have any marked effect upon the organ. When the 
fibrous capsule was torn off it presented a light slate color, and yet 
when magnified and carefully examined, but few of these dark 
masses were seen in the meshes. The structures of the liver, and 
the liver-cells, contained numerous oil-globules. These oil-glo- 
bules existed in sufficient numbers to induce the belief that the 
liver was in a state, not only of cirrhosis, but also of fatty degene- 
ration. The bloodvessels of the liver were filled with dark blood, 
which did not change to the arterial hue upon exposure to the 
atmosphere. 

The mottled appearance of the liver, and the want of that decided 
slate and bronze color characteristic of malarial fever, w^ere due not 
to any peculiarity of the effects of the malarial poison, but rather 
to the pathological conditions of cirrhosis and fatty degeneration. 
Allowing due weight to these pathological changes, it is evident 
that the change in the color of the liver was similar in all respects 
to the slate, or bronze color of livers, which were normal before the 
onset of the malarial fever. The change in the color of the liver 



882 



OBSEKVATIONS ON 



during malarial fever is due to changes in the an^ount, and physical 
and chemical constitution of the blood in the capillaries of the liver, 
and to the physical and chemical changes in the bile and the con- 
tents of the secretory apparatus, and not to the deposition of black 
granules in the structures of the liver. I have seen the slate and 
bronze color as well marked in the liver when these dark masses 
were absent, as in the liver where they were most abundant. The 
peculiar color of the liver is due, in a great measure, to changes in 
the coloring matter (haematin) of the blood. The blood will not 
change to the arterial hue when exposed to the atmosphere. This 
altered coloring matter resulting from the destroyed disintegrated 
blood-corpuscles, or from the blood-corpuscles acted on by the 
malarial poison, without actual disintegration, escapes and permeates 
the surrounding tissues and imparts the peculiar color to the liver. 
The color is also due to the altered color of the bile. 

In all the cases of malarial fever which I have thus far examined, 
I have found the bile to be of high specific gravity, thick, concen- 
trated, and of a greenish-black color, when seen in mass, and of a 
gamboge yellow when spread in thin layers. The altered bile also 
infiltrates the surrounding tissues and gives this peculiar color to 
the liver. This peculiar color can be to a certain extent abstracted 
from the liver by boiling with water. I have always found the 
filtered decoction of malarial fever livers to be of a brownish- 
yellow color, whilst the decoction of yellow fever livers is of a 
bright golden color, whilst that of normal livers is of a light- 
yellow. After the altered coloring matters of the blood and bile 
have infiltrated the structures of the liver, they will sometimes re- 
main for a considerable length of time without being absorbed, and 
communicate the peculiar bronzed color to the liver long after the 
restoration of its normal functions, and the disappearance of the 
malarial fever. I have observed, however, that the intensity of the 
color of the liver bears a marked relation to the time of convales- 
cence; as convalescence advanced the color diminished in depth. 

The liver contained animal starch. Several of the hepatic ducts 
were isolated and treated with tincture of iodine and carefully ob- 
served under the microscope. Their color, with the exception of 
a few small spots, was simply changed to that of the tincture of 
iodine. In these spots, the color was changed to a bright blue. 
In other cases of malarial fever, I have seen long portions of the 
hepatic ducts changed to a bright blue color under the action of the 



MALAEIAL FEVER. 



883 



tincture of iodine. These facts would show that they do sometimes 
contain animal starch. 

The gall-bladder was filled with concentrated bile of the consist- 
enc}' of molasses, and of the color (when seen in mass) of a satu- 
rated solution of iodine. When spread in thin layers the bile 
presented a gamboge color. 

Spleen enlarged. It was at least three times the normal size. 
The structures of the spleen were so mucli disorganized, that in 
attempting to remove it from the abdominal cavity, the capsule and 
trabeculae gave way under a slight pressure, and the fingers 
plunged into its soft substance. Dark brownish purple, almost 
black mud flowed from the rupture. After thirty-six hours' expos- 
ure to the atmosphere, the color of the mud of the spleen remained 
unchanged. 

Under the microscope, the mud of the spleen contained a great 
number of dark, reddish-brown and reddish-black granules, and 
conglomerations of granules. These granules and black masses, 
composed of conglomerated granules, resembled the bodies found 
in the liver, and also the black sediment of the black vomit of yel- 
low fever. 

Similar granules and masses have been observed in normal 
spleens. They appear, however, to be most abundant in the mala- 
rial fever spleens of long standing. In cases which have terminated 
fatally after only a short illness of only two or three days, I have 
observed that these granules were not so numerous as in cases of 
longer duration, and in some very recent cases they were not more 
numerous than in the spleen of health. These masses appear to 
be derived from the disintegrating blood-corpuscles. 

Alimentary and Intestinal Canal, Stomach. — Bloodvessels upon 
its exterior filled with blood. Mucous membrane bore no marks 
of inflammation, and was not more congested with blood than usual. 
The exterior and mucous membrane of the jejunum presented the 
usual appearance. There was no unusual appearance either of con- 
gestion, irritation, or inflammation. The mucous membrane of the 
ileum, especially at the lower portion, was more congested, and of 
a darker color than usual. 

The intestinal canal throughout its entire length was empty. 
The mucous membrane presented a yellowish appearance, probably 
due to the presence of bile. 

The solitary glands of the ileum especially in the neighborhood 
of the ileo-csecal valve, were numerous, enlarged, elevated, distinct. 



384 



OBSERVATIONS ON 



and of a brown color. When the intestines were held up to the 
light, the bloodvessels filled with blood could be distinctly seen send- 
ing off branches to each gland. The glands of Peyer were large, dis- 
tinct, and elevated. Several of these glands in the lower portion 
of the ileum, were three inches in length. These glands, however, 
were not inflamed, as in typhoid fever, but presented the usual 
pale appearance. 

Kidneys. — Each kidney had upon its inferior surface a spot about 
one inch in diameter, of a slate color, resembling, in all respects, 
the color of the exterior of the malarial fever liver and spleen. 
When these portions of the kidney were cut, they presented a 
bronzed color for the depth of one-eighth of an inch. Microsco- 
pical examination showed the absence from these portions of the 
liver of those granules, and brownish-red and reddish-black masses, 
so abundant in the spleen and liver. Microscopical examination 
showed that the excretory structures of the kidney were not altered 
in these discolored portions. 

These facts sustain the assertion that I have previously made 
that the color of the liver in malarial fever does depend upon the 
diffusion through its substance of dark granules and granular 
masses. The bladder was empty. The scrotum was reddened, and 
appeared to be blistered and excoriated. This was due to the ac- 
tion of the intensely acid urine. 

CONCLUSIONS. 

1. This case corresponds to the congestive fever of American 
writers. The prominent symptoms of this case were rapid, full 
pulse ; rapid, thoracic respiration ; relaxed skin, with cold clammy 
sweat ; sluggish capillary circulation ; deficient and perverted 
chemical action ; reduced temperature ; deranged physical, muscu- 
lar, and nervous forces; and aberrated intellectual action. 

2. The rapid, feeble, action of the heart; the rapid, feeble pulse; 
the almost entire arrest of the circulation and chemical changes in 
the capillaries, were attended by a reduction of temperature, and 
loss of muscular and nervous force, and aberration of the actions 
of the sympathetic and cerebro- spinal nervous systems. These 
disturbances of the chemical changes, and physical, muscular, and 
nervous forces were reflected in the urine. The appearance and 
chemical constitution of the urine were strikingly different from the urine 
of those cases of intermittent and remittent fevers where the action of the 



MALARIAL FEVER. 



885 



poison is attended hy an excitement of the general and capillary circula- 
tion and of the respiration^ and corresponding rapid chemical changes^ 
and high temperature. In those cases of malarial fever where there 
is a rapid, full pulse; moderately accelerated respiration; rapid 
introduction and distribution of oxygen and corresponding high 
temperature, the urine is invariably high-colored, concentrated, and 
rich in solid matters. 

If we examine the analyses of the nrine of those cases of inter- 
mittent and remittent fever, which have been previously recorded ; 
and, at the same time, bear in mind the fact that the urine was 
excreted during the summer season, and during starvation; it is 
evident that during the febrile excitement the urea is greatly in- 
creased. 

When the febrile excitement (rapid distribution of oxygen, and 
rapid chemical change, and high temperature) subsides, the urea 
and other solid constituents of the urine decrease. 

After "the establishment of convalescence, when the patient is 
able to take food freely, the solid constituents of the urine again 
rise, notwithstanding that the temperature is the same, or a few 
degrees above that of the intermission. The "urea during convales- 
cence is probably derived partly from the food, and partly from 
the metamorphoses of the tissues. In this case, on the other hand, 
the arrest of the circulation and chemical changes of the capillaries, and 
the reduction of temperature^ was attended hy a complete alteration of 
the physical and chemical constitution of the products resulting from the 
metamorphoses of the blood, organs, and tissues. The urea and uric 
acid were absent, the acid of the urine was greatly increased, and the 
physical properties of the urine altered. 

Whether the disappearance of the urea and uric acid resulted 
from the arrest of the metamorphoses of the muscular tissue, or of 
the blood-corpuscles and nitrogenized elements of the blood ; or 
from the disturbance of the normal chemical changes, by the intro- 
duction of the malarial poison, amongst the substances undergoing 
chemical change ; or from the primary action of the malarial poison 
upon the sympathetic and cerebro-spinal nervous systems, and the 
perversion of the chemical changes of the organized elements, by 
the consequent aberrated nervous action ; cannot be definitely an- 
swered in the present state of chemical, physical, physiological and 
pathological science, because the fundamental facts are wanting. 

Whilst it is known that urea and uric acid are products of the 
chemical changes of the nitrogenized elements, still it has not as 



386 



OBSEEVATIONS ON 



yet been definitely settled whether urea and uric acid^ result from 
the metamorphoses of the blood-corpuscles, or of some one special 
nitrogenized constituent of the blood, or of the muscular tissue : 
or from all these sources. 

The chemical, physical, physiological and pathological properties 
and relations of the malarial poison are unknown. What relations, 
chemical, physical, physiological and pathological, do the meta- 
morphoses of the organized bodies which result in the formation 
of urea and uric acid, and of the extractive and coloring matters, 
bear to the metamorphoses induced by the malarial poison ? It is 
impossible to give any answer to this important question, which 
lies at the foundation of the solution of the problem. 

Neither would the answer of this important fundamental ques- 
tion clear up the difiiculty, for we have here complicated pheno- 

' The following observations are interesting in their bearings upon the origin of 
uric acid. I kept a large Indigo snake (coluber couperi) in a cold, dry room, during 
the winter season, without food and drink. This serpent remained in a partially 
torpid state for three months. He was never entirely without the power of motion, 
and would, when aroused, show considerable power. At the end of this time the 
serpent died. When the heart was exposed after death, its surface was covered with 
a chalky granular substance, which was demonstrated both by microscopical and 
chemical analysis, to be the urate of ammonia. The external surface of the aorta 
and its largest branches were in like manner covered with the urate of ammonia. 
When the substance of the heart was cut, numerous particles of the urate of am- 
monia were found along the course of the bloodvessels and amongst the muscular 
fibres. Numerous particles of the urate of ammonia were also discovered amongst 
the fibres of the muscular coat of the aorta and its largest branches. When a 
portion of the muscle of the heart, or of the muscular coat of the aorta was treated 
with, acetic or hydrochloric acid under the microscope, thousands of small lozenge- 
shaped crystals of uric acid were discovered lying around the muscular fibrillae. 
The urate of ammonia was deposited in no other organ or tissue except the heart 
and the aorta, and its largest branches. The following appears to be the explanation 
of this singular phenomenon : The heart was the only portion of the muscular 
system in continual action during the season of hybernation. Muscular force is 
developed by chemical change. The heart, therefore, was the only portion of the 
muscular system undergoing chemical change. The blood was concentrated, defi- 
cient in water. There was not sufficient water to dissolve the urate of ammonia, 
resulting from the chemical changes of the blood and muscles of the heart, by which 
the muscular force was developed. The urate of ammonia consequently remained 
just where it was formed. This observation not only points to the origin of uric acid 
and ammonia in the animal economy, but also demonstrates that the muscular force is 
developed during the chemical changes of the elements, of the blood and muscles. If 
these conclusions be legitimate, true and universal, it follows as a necessary consequence^ 
that any alteration in amount or kind of the chemical changes of the blood and muscular 
tissue, must be attended by corresponding alterations in the amount and kind of the 
products resulting from those chemical changes. 



MALAKIAL FEVER. 



387 



mena and numerous complicated actions and reactions. So com- 
plicated and involved are the phenomena that the solution of one 
necessarily demands the solution of all. 

Such questions as these demand an answer: — 

What is the chemical, physical, physiological and pathological 
relations of the malarial poison to the sympathetic and cerebro- 
spinal nervous systems ? 

What is the effect of derangement of the sympathetic nervous sys- 
tem upon secretion and excretion, in fact upon all chemical changes 
of the elements of the human organism ? 

Will the derangement of the secretions and excretions differ 
with different poisons, when the actions of those poisons are limited 
simply to the sympathetic nervous system f 

What is the effect of derangement of the sympathetic nervous sys- 
tem upon the cerebrospinal nervous system ? 

Can the sympathetic nervous system induce alterations in the actions 
of the organs and tissues, in the secretions and excretions, inde- 
pendent entirely of any direct action, but by communicating or re- 
flecting its aberrated action to the cerebro-spinal nervous system? 

What is the effect of derangement of the cerebrospinal nervous 
system, upon secretion and excretion, in fact upon all the chemical 
changes of the elements of the human organism ? 

Will the derangements of the secretions and excretions differ 
with different poisons, when the actions of those poisons are limited 
simply to the cerebrospinal nervous system,! 

AYhat is the effect of derangement of the cerebrospinal nervous 
system, npon the sympathetic nervous system ? 

Can the cerebro-spinal nervous system induce alterations in the 
actions of the organs and tissues, in the secretions and excretions, 
independent entirely of any direct action, but by communicating 
or reflecting its aberrated action to the cerebrospinal nervous system. 

Would the phenomena of nervous and muscular action and of 
secretion and excretion, vary, if the action of the poison or poisons 
were primarily upon the blood, rendering it unsuited to the healthy 
action of the cerebro-spinal and sympathetic nervous systems and 
of the muscular system, rendering it unsuitable for the formation 
of the secretions and excretions? 

ISTotwithstanding the absence of the facts necessary for the abso- 
lute solution of these complicated phenomena, and problems, still 
the present observations, that arrest of capillary circulation and 
chemical change, due to the action of the malarial poison, was 



388 



OBSERVATIONS ON 



attended by a reduction of the temperature, aberrated muscular and 
nervous action, and a marked alteration of the properties of the 
nrine, are of great interest in their bearing upon the treatment 
of congestive fever. 

3. In the treatment of that form of malarial fever called congest- 
ive fever, those remedies should be employed, which excite the 
general and capillary circulation, promote the introduction and 
distribution of oxygen, increase the chemical changes, and excite 
the development of the muscular and nervous forces. Sulphate of 
quinia and diffusible stimulants, brandy, and carbonate of ammonia 
should be freely and promptly administered, and sinapisms freely 
applied. Bottles of hot water, or, better still, the hot water bath, 
should be used to impart heat and stimulate the capillary circula- 
tion, and relieve the engorgemeut of the large organs. Brandy 
and red pepper may be applied to the surface with advantage. 
The sulphate of quinia may be administered in doses of 15 to 30 
grains every one, two, or three hours, according to the urgency of the 
symptoms, up to from 30 to 100 grains during the twenty-four hours. 
The best method of administering the sulphate of quinia is dissolved 
in a weak solution of citric acid or in lemon juice. It is perfectly 
soluble in this, and is much more readily absorbed when in this 
soluble form. If the stomach rejects the sulphate of quinia, it 
should be administered in solution with starch, by the rectum. 
These stimulants will in many cases be the means of prolonging 
life until the sulphate of quinia can be absorbed and act. Whilst 
therefore the stimulants do not cure the disease, they often preserve 
life by supporting the patient until the sulphate of quinia can act. 

The carbonate of ammonia is peculiarly valuable in that form of 
malarial fever where there is a rapid feeble pulse and corresponding 
rapid feeble action of the heart. The observations which I have 
recorded in the previous numbers of this journal prove that heart- 
clots are almost always formed previously to death from malarial 
fever. It is probable that cases often occur where the sudden and 
distressing symptoms are due in a great measure to the formation 
of these heart-clots during life.^ The feeble action of the heart, 

' The following observations of Dr. Chisliolm are exceedingly interesting in 
their bearings upon the preceding investigations upon the formation of fibrinous 
concretions in tbe heart and bloodvessels, during malarial fever : — 

"A Shokt Account of the Epidemic Polypus at Grenada, in 1790. 

"The situation in which this singular disease appeared is rather peculiarly 
circumstanced. The foreground is the sea, perfectly open, with an extensive and 



MALARIAL FEVER. 



889 



aad the sluggish circulation of the blood, are very favorable to 
the formation of these heart-clots. The free administration of the 

burning beacTi of sand ; on the left is a Mil of considerable and steep ascent, tbe 
base sides of wbicb, in conjunction with, the reflecting surface of the sea, produce 
in dry seasons an immense degree of heat ; on the right the view is limited bj a 
mountain of great height and magnitude ; the background is a marsh extending 
from the sea to the mountains, and formed chiefly by water rushing from a narrow 
stony ravine, and dammed up by a beach rendered impenetrable by the surge : 
from this marsh vapors of a very deleterious nature continually exhale, and this 
was particularly observable in the month of October of this year, on account of the 
trees and brushwood, which hitherto had covered it, being cut away in order to 
drain the marsh. Immediately behind the marsh the ravine begins, and runs 
back between the hill and mountain, in the form of a funnel, gradually rising for 
upwards of a mile. Through this ravine there is a continual current of wind of 
an uncommon degree of coolness. The negro houses of the plantation are built on 
the left, chiefly on its slope, and towards the edge of the marsh. The negroes were 
consequently at once exposed to excessive heat, a cold chilling current of air, and 
the miasma of the marsh. Their diet was chiefly composed of vegetable food. 
They had been employed immediately before the appearance of the disease in 
question, in clearing the surface of the marsh, and in holing land for the reception 
of cane plants. Like all other negroes placed in similar situations (marshy), they 
were much given to the destructive habit of eating a species of pipe-clay, very 
abundant in Grenada. 

"The disease made its appearance on the plantation Grrand-mal, about the end of 
September or beginning of October ; was most prevalent towards the close of the 
latter month, and disappeared totally in November. The whole number of sick 
might have been forty, of whom seven died. Its commencement was marked by 
no distinguishing symptom ; but soon after, the patient complained of pain at the 
pit of the stomach and in the head, and difficult respiration. These pains were 
attended with a dry skin, small quick pulse, and slight frequent dry cough. No 
febrile heat accompanied these symptoms ; on the contrary, the surface was at 
this period remarkably cool ; but a heaviness and dulness of eye, a melancholy or 
depression of spirits, and features strongly expressive of anxiety were constant 
attendants. The state of the patient was thus characterized for three days. At 
the expiration of that period, the pulse became extremely quick, 120 to 140, and 
intermitted, attended with a penetrating pungent heat, which produced a pricking 
sensation on the hand of the person feeling the pulse. But this state of the pulse 
and heat, as well as the pains, anxiety, and other distressing symptoms, now also 
intermitted, or rather the disease assumed something like an intermittent form, 
the intermission of it may be so called, continuing eight or nine hours. During 
the paroxysm, the struggle for breath, the aggravation of all the other symptoms, 
and the very quick, interrupted, and evidently visible, as well as audible palpita- 
tion of the heart, produced a scene of uncommon horror. The paroxysm was suc- 
ceeded by a cold clammy sweat, and a state of approaching syncope. The second 
paroxysm generally put a period to the existence of the patient. The disease was 
also distinguished during this latter stage, and even for some time previous to its 
commencement, by a constant or almost constant disagreeable clammy sweat over- 
spreading the face, the upper extremities and the body as low down as the scrobi- 
culus cordis, all below remaining arid and parched in a most remarkable degree. 



390 



OBSERVATIONS ON 



carbonate of ammonia, in congestive fever, will fulfil two indica- 
tions: 1st, stimulation; 2d, prevention of the formation of fibrinous 
clots in the heart and large bloodvessels. 

The disease seemed sometimes inclined to terminate by metastasis ; one instance 
of this was remarkable, wherein a spontaneous absorption of the lymph deposited 
in the heart, and a deposition of it in the left arm and left thigh took place. The 
patient, in this case, after laboring under all the symptoms peculiar to the disease 
before the intermittent period, found himself all at once, and without an evident 
cause, relieved of them ; but he perceived at the same instant an excruciating pain 
a little above the elbow, and nearly about the middle of the thigh. He continued 
ever after absolutely free of all the symptoms of the polypus ; but they were suc- 
ceeded by a large abscess in the parts in which he felt the pain. That in the arm 
disappeared gradually, but the other became so large as to occupy the whole of 
the under part of the thigh. The cure was effected by passing a seton through 
the whole length of the tumor ; by the use of two dozen of Madeira wine, a large 
quantity of bark, and a calomel pill, with opium three times a day. The audible- 
ness of palpitation may be considered as exaggeration ; but in one instance par- 
ticularly, the gentleman (Mr. M'Sween) to whom the negroes belonged, heard 
distinctly the palpitation, although in an adjoining room. 

" What mode of practice did so extraordinary a train of symptoms indicate ? I 
could fix on none till dissection instructed me. Having no suspicion of the heart 
being the seat of this uncommon malady, I did not examine that organ in the two 
first bodies I opened ; but finding all the other viscera, and the brain in a state of 
health, I found myself still unable to account for the extraordinary symptoms the 
patients had been afflicted with. At length, on opening the third body, I examined 
the heart, and discovered what I conceived might be considered the cause and 
seat of the disease. In the right ventricle of the heart I found a polypus which 
extended considerably into the pulmonary artery. On extracting it, it measured 
exactly two feet and two inches in length ; and the body of it contained, in the 
ventricle, two inches in breadth. In the fourth body there was a very large poly- 
pus in the right and left ventricle, besides one in the right auricle. The hearts of 
the fifth, sixth, and seventh, were circumstanced precisely similar ; and in the 
five, except one where the lungs were morbidly affected, no other morbid appear- 
ance of any description could be perceived. Did these extraordinary circumstances 
justify the appellation — epidemic polypus ? 

"After a variety of ineffectual attempts to cure this disease, I determined on the 
following, and found it successful : From the consideration of the circumstances 
contributing to the production of the disease, so far as they were discovered ; of 
the features of the disease itself ; and of the morbid changes observed in the dead 
bodies ; it may be fair to conclude, that a laxity of fibre, a want of due cohesion 
in the mass of blood, and a consequent deposition and accumulation of coagu- 
lable lymph in the cavities of the heart, where the various valves and columnae 
favor such accumulation, produced polypi, an interruption, and at length a total 
stop to the circulation. Having this view of the disease, it was manifest that such 
means as might prevent deposition and accumulation of coagulable lymph, or 
destroy it, should it have happened, in the first instance ; and afterwards restore 
tone to the fibre, would cure the disease. The action of mercury on the absorbent 
system I had for some time been acquainted with, and its probable efficacy in that 
way here, readily occurred to me. My mode of treatment, therefore, was this : 



MALARIAL FEVER. 



891 



4. The failure of this mode of treatment to prevent a fatal termi- 
nation in this case was due to several causes. The disease had 
been allowed to progress without any opposition for at least ten 
days before this plan of treatment was instituted. During this time 
such profound alterations of the blood, spleen, and liver had taken 
place, and the chemical changes so perverted and the correlation 
of the physical, vital, nervous, and muscular forces, so disturbed, 
that no plan of treatment, however vigorous, however appropriate, 
could arrest the progress of the disease. 

The symptoms were without doubt aggravated by the cirrhosed 
condition of the liver. The alterations of the color of the blood 
and of the secretions of the liver in malarial fever, point to pro- 
found alterations. The cirrhosed condition of the liver would 
necessarily increase these morbid effects. The cirrhosed condition 
of the liver also points to the former intemperate habits of the 
patient, and the effects of these upon the constitution, no doubt 
influenced materially the course of the disease. As far as my ob- 
servations upon malarial fever extend^ I can assert that this disease 
most frequently proves fatal in those who have been addicted to the 
intemperate use of ardent spirits^ and especially in those in whom a 
cirrhosed condition of the liver has been induced by the free use of ardent 
spirits. This statement is worthy of the attentive examination and 
consideration of the profession. 

It is probable that the fibrinous clots found in the heart were 
formed some time before death, and if they did not determine^ they 
at least hastened the fatal termination. 

5. In this^case the marked reduction of the temperature of the 

The moment I could distinguish, the disease, I bled, in order to render circulation 
through the lungs and heart less difficult and obstructed. This evacuation was 
never repeated without great caution, and the most evident necessity. After this 
I gave calomel in doses of five grains, guarded with opium, every fourth hour, and 
continued it until salivation was excited. Under this treatment I lost not a single 
patient, the fatal terminations having taken place before I could carry it fully 
into execution. 

" A pneumatic physician would probably refer all to the hydrocarbonate of the 
marshy exhalations, and attribute the cure to the oxygen disengaged from the 
mercury, assisted by the stimulus of the metal. Whether such might be correct 
reasoning or not, I am certainly induced to consider the history taken altogether 
as an illustration of the theory of the curative action of mercury in the system ; 
and as such I have judged it worthy of the reader's notice." (An Essay on the 
Malignant Pestilential Fever introduced into the West Indian Islands from Boullam, 
on the Coast of Guinea, as it appeared in 1793, 1794, 1795, and 1796. By C. 
Chisholm, M. D. London, 1801, vol ii. Appendix No. 6, pp. 454—460.) 



392 



OBSEKVATIONS ON 



trunk and extremities was unattended by the shivering and sensa- 
tions of cold characteristic of the chill of intermittent and remittent 
fever. 

The observations which I have recorded have established that in 
the chill of intermittent and remittent fever the temperature of the 
trunk is actually elevated several degrees above the normal stand- 
ard, whilst the temperature of the extremities is depressed many 
degrees below the normal standard. In this state of things we find 
a feeble pulse, feeble circulation of the blood in the capillaries of 
the extremities, diminished chemical action in the capillaries of the 
extremities, accumulation of blood in the large organs of the trunk, 
and increased chemical change in the blood and large organs of the 
trunk. This state of things is attended by shivering of the muscles 
and a sensation of cold, just as a similar reduction of the tempera- 
ture of the extremities in cold weather would be attended by shiver- 
ing of the muscles and a sensation of cold. 

On the other hand, in that form of malarial fever called congestive 
fever^ where the temperature of both the trunk and extremities is 
depressed, the patient often complains of no sensation of cold, and, 
in some instances, even says that he feels perfectly well, and there 
is no shivering of the muscles. Here we find a feeble general and 
capillary circulation and an arrest and perversion of chemical 
action, both in the trunk and in the extremities. 

Whence this difference? 

Without attempting to decide dogmatically upon the solution of 
these complicated phenomena, we would simply state that in con- 
gestive fever the chemical changes in all parts of the body are so 
diminished and perverted, and the correlation of the forces so 
disturbed, that the muscular system ceases to indicate by shivering 
and aberrated action, and the nervous system ceases to indicate by 
the sensation of cold, the depression of temperature consequent 
upon the arrest of capillary circulation and chemical change. As 
muscular and nervous force, and even sensation, depend upon 
chemical change, it is but reasonable to suppose that a marked 
perversion and diminution of chemical change should be attended 
by an arrest of muscular and nervous action, and even of sensation. 
In congestive fever, whether from peculiarities of constitution or 
from the overwhelming amount of the poison introduced, those 
chemical changes are not excited, which result in the breaking up 
and removal of the malarial poison. 

The febrile excitement following the chill of intermittent and 



MALAEIAL FEVEE. 



893 



remittent fever, appears to be due to the equalization of the general 
and capillary circulations; and to the distribution through the blood- 
vessels and capillaries of all parts of the body, of the substances 
undergoing active chemical changes, developing high temperature, 
which during the chill were confined to the trunk. 

The equalization of the capillary and general circulations is, 
without doubt, dependent in great measure, primarily, upon the 
action of the sympathetic nervous system ; and, perhaps, may be 
secondarily and remotely affected by the action of the cerebro- 
spinal nervous system. We say dependent in great measure^ but 
not absolutely, and entirely, upon the sympathetic nervous system ; 
because the malarial poison may act, in addition to the modes 
already pointed out, directly upon the fibres of the heart, and thus 
influence circulation, and through it respiration, and chemical 
change, and temperature, and muscular and nervous force, and the 
manifestation of intellectual phenomena, independently altogether, 
of any direct and primary action upon either the sympathetic or 
cerebro-spinal nervous systems. 

It is highly probable that, during the febrile excitement, the 
malarial poison is drawn into the round of chemical changes, and 
so altered, that its action is for a time suspended. Hence the in- 
termission, or remission. 

The fever ^ then, is a favorahle symptom, and the want of fever, a 
most unfavorable symptom; and if these views be true, the paroxysms 
of malarial fever are due to the alterations and partial destruction 
of the poison during the active chemical changes of the febrile ex- 
citement. 

The manifest duty of the physician in congestive fever (if these 
views, which have been suggested by the results of actual observa- 
tion and experiment, be correct), is to administer those remedies 
which will excite the general and capillary circulations — excite 
chemical change — excite fever, and arouse into vigorous action the 
sympathetic nervous system, and destroy, or counteract, or paralyze 
the action, or eliminate the malarial poison. 

Case illustrating the Power and Rapidity of the Action of the 
Malarial Poison in Congestive Fever and Changes of Blood in 
THE Liver and Spleen. 

American seaman ; age 25 ; height 5 feet 9 inches ; weight 150 
pounds ; dark complexion, dark-brown hair, brown eyes. 
26 



394 



OBSERVATIOXS OX 



October 19, 1857, 8 o'clock P. M. This patient entered the hos- 
pital three hours ago, at 5 o'clock P. M., in an alnaost insensible 
condition. iSTow he is aroused with great difficulty and answers 
incoherently. Extremities cold. Pulse 80, feeble. Head and trunk 
cooler than normal. Tongue by the gas light appears clean, soft, 
and normal in color. 

R. — Cut cups to each temple and back of neck. 

B. — Mustards to extremities and over epigastric region. 

R. — Sulphate of quinia gr. v; camphor gr. ij. Mix, and admi- 
nister every three hours until fifty grains of the sulphate of quinia 
have been taken. 

R. — Spirit of mindererus, brandy, and infusion of snakeroot 
f^ss of each, alternately every half hour. 

20th, 9 o'clock A. M. Lies in a profound coma. This came on a 
short time after the first observation yesterday evening. The cut 
cups aroused him partially for a few moments, but he soon relapsed. 
Mustards have been applied to the extremities and epigastric region 
three times during the night ; they failed to rouse the brain ; they 
excited the capillary circulation and induced an elevation of tem- 
perature, but did not restore reason. The stimulants also failed to 
arouse the intellect. Whenever the mustards were removed and 
the stimulants withheld his surface became cool and the pulse 
diminished in volume. It is evident, then, that the mustards and 
stimulants excite the general and capillary circulation, and induce 
an elevation of temperature, but they do not arrest the disease. 
During the night has passed his urine and feces in bed. Pulse 140, 
full. The sounds of the heart are not distinct ; they cannot be dis- 
tinguished, but sound to the ear like one sound. The beating of 
the heart-sounds stronger even than in health. The sounds of the 
heart correspond in frequency to the beat of the pulse, 140 to the 
minute. Kespirations 40, spasmodic. Temperature of atmosphere, 
70° P.; temp, of hand, 104°; temp, in axilla, 104.5°. Great ten- 
derness of epigastrium. Whilst neither shaking nor loud talking 
will arouse him, pressure upon the epigastrium causes him to emit 
a short cry. The epigastrium and region of the liver feel to the 
hand warmer than the head or any other part of the body. Com- 
plexion very sallow. I administered gr. xxx of sulphate of quinia 
in f^ij of brandy. It was with great difficulty that the spoon was 
forced between his clenched teeth. The dose had not been swal- 
lowed more than a few moments before it was ejected violently, 
apparently without any effort or consciousness on the part of the 



MALAKIAL FEVER. 



395 



patient. This dose was again repeated, and his trunk and extremi- 
ties covered with mustards, and bottles of hot water applied to the 
feet, without producing the slightest good effects. This patient died 
one hour and a half after these ohservations. 

AUTOPSY TWENTY-FOUR HOURS AFTER DEATH. 

Body not emaciated ; apparently in full flesh. Has the marks of 
a large ulcer over the superior portion of the sternum. Skin of 
the dependent parts of the body of a purplish hue. The discolora- 
tion of the skin commences about the middle of the body and 
gradually increases downwards, until the most dependent portions 
are of a deep purple color. 

Head. — When the skullcap was removed, much blood flowed 
out. Arachnoid membrane opalescent, in a few spots. Blood- 
vessels of pia mater filled with blood. Bloody serum was effused 
between the arachnoid and pia mater. Bloodvessels at the base of 
the brain and surrounding the medulla oblongata and superior 
portion of the spinal cord, congested with blood. Blood was ef- 
fused upon the base of the brain. This blood was fluid, and con- 
tained no coagula. The substance of the brain was normal in 
consistence and appearance. 

Chest. — Hearty normal ; right auricle and ventricle contained a 
small clot, left heart empty. Lungs, normal; dependent portions 
congested with blood. Bloodvessels of superior portions almost 
entirely free of blood. 

Abdomen — Liver. — A large portion of the surface of the liver 
presented the healthy Spanish brown color, and, when cut, the 
substance presented the usual healthy color. Other portions, how- 
ever, presented a mottled appearance of Spanish brown and dark 
purple, and the bloodvessels of these parts appeared to be engorged 
with- blood. The right lobe of the liver had upon its under surface 
a spot about two inches in diameter, of a dark slate (malarial) color. 
When an incision was made through this portion of the liver, it 
presented for the depth of about one-fourth of an inch, the true 
bronze color. Numerous incisions were made into the liver in all 
directions, so as to expose its substance fully to view ; portions 
were found approaching in color the bronze hue of the malarial 
fever liver ; the great mass of the liver, however, resembled more 
nearly that of a healthy liver, engorged with blood. Portions from 
different parts of the liver were examined under the microscope. 



896 



OBSERVATIONS ON 



The liver cells from the slate colored and bronzed portions did not 
differ in appearance, under the microscope, from those of the nor- 
mal colored, or from those of the mottled portions. The colored 
corpuscles appeared to be more altered in form in the bronzed 
portions than in the normal colored portions. The alterations, 
however, even in the bronze portions, were small and bj no means 
universal, but confined comparatively to a few, and, after all, the 
difference may have been imaginary. The determination of com- 
parative alterations of this kind is not so easy as at first sight 
appears. Did not discover any of those dark granules in the bronze 
portion, which have been said to impart the peculiar color to the 
liver. From the cut surface of the liver, much black blood issued, 
which assumed, upon exposure to the atmosphere, the arterial hue. 
The liver-cells did not appear to be altered in any manner. 

GaU-hladder^ filled with bile. Specific gravity of bile, 1042.5. 
Viewed in mass, the bile was of a brownish-black color, with 
greenish reflections, and resembled, upon a general view, a satu- 
rated tincture of iodine. It resembled, and poured like molasses, 
being thick and ropy. Upon close inspection, the bile was found 
to contain numerous flakes of a green color, w^hich, under the 
microscope, were found to consist of the conglomerated cells of the 
mucous membrane of the gall-bladder. When spread out in thin 
layers, the bile presented a gamboge, yellow color. 

Pancreas, normal. 

Spleen, slate colored, softened and enlarged ; not as much softened 
and altered, however, as in cases of malarial fever of longer stand- 
ing. The mud of the spleen was of a dark purplish hue, and ap- 
peared to be in transition to the color and state of the mud of the 
spleens of malarial fever of longer duration. After exposure for a 
few hours to the oxygen of the atmosphere, a large portion of the 
mud of the spleen assumed a color approaching the arterial hue, 
much brighter than the mud of the spleens upon which malarial 
fever had exerted its full effects, and somewhat darker than the 
bright arterial hue assumed by the splenic mud of healthy, normal 
spleens. When the splenic mud was spread in thin layers upon a 
glass slide, the change of color was much more rapid. Under the 
microscope, the splenic mud appeared to consist almost entirely of 
colored corpuscles, many of which appeared swollen and altered in 
appearance. After careful examination, I was unable to find those 
conglomerations of black granules, resembling the black sediment 
of black vomit, which were discovered in other malarial spleens. 



MALARIAL FEVER. 



897 



Kidneys^ normal. Bladder contracted ; contained no urine. Scro- 
tum red, and apparently scalded. This was due most probably to 
the acrid urine. / have observed this effect of the urine upon the 
scrotum in many cases of malarial fever of the severest types. 

Alimentary and Intestinal Canal. — The mucous membrane of the 
stomach presented two well-defined portions : the mucous mem- 
brane of the lesser curvature of the stomach was pale and normal 
in appearance ; the mucous membrane of the greater curvature and 
pyloric extremity, and of the pylorus, was of a purplish color, and 
ecchymosed in crimson spots. The bloodvessels of the greater 
curvature and of the pylorus were congested with blood. Mucous 
membrane of the superior portion of the jejunum congested with 
blood. Yalvulae conniventes, especially at the edges, ecchymosed 
in spots of a purple and scarlet color. Mucous membrane of the 
lower portion of the ileum greatly congested with blood. Peyer's 
glands somewhat enlarged, more distinct and elevated than usual, 
but pale, and not congested and inflamed as in typhoid fever. Soli- 
tary glands enlarged and distinct. Mucous membrane of colon 
greatly congested with blood. 

CONCLUSIONS. 

1. The slight alteration of the color of the liver; the change of 
the blood of the liver to the arterial hue upon exposure to the 
atmosphere ; the change of the splenic mud to the arterial hue — 
all prove that this patient had died very soon after the commence- 
ment of the malarial fever. As we have seen, the patient was 
unable to answer any inquiries with reference to the history of his 
case. So convinced was I that this was a case of only one or two 
days' standing, that I sought out the captain of the vessel to which 
this patient belonged, and made minute inquiries. The captain 
stated that this man was the cook on the vessel. One month ago, 
whilst the vessel was lying in the Santee River of South Carolina, 
this patient was taken with a fit. This was relieved in a few hours, 
and was not followed by fever ; and the patient appeared to suffer 
no ill effects, and resumed his duties. Two weeks ago the captain 
brought his vessel to Savannah. This patient has been sleeping 
on board the ship at night up to the time of his entrance into the 
hospital. He was well, active, and attentive to his duties, up to 
5 o'clock P. M., October 18, when he was suddenly seized with 
vomiting, cold extremities, complete prostration, and delirium. He 



398 



OBSEEVATIONS OX 



had cooked dinDer this day, and was attending to his duties at the 
time of this sudden attack. He had, however, "a singular look 
out of his eyes," which attracted the attention of the captain, and led 
him to inquire if he was well; the patient answered yes, and com- 
plained of nothing. Whilst sick on board the ship, he complained 
of no pain ; and, before the complete loss of reason, said that he 
felt well. The next day, the 19th inst., he was sent to the hospital 
at 5 o'clock P. M. I saw him for the first time at 8 o'clock P. M. 
He died at 12 o'clock M. the next day. This patitnt^ then^ died after 
forty-three hours' sickness. 

2. The general and capillary circulations were easily aroused by 
stimulants; the temperature of the body, under the action of stimu- 
lants, was elevated above the normal standard ; there was a corre- 
lation between the temperature of the trunk and extremities ; the 
chemical changes appeared to be amply sufficient for the develop- 
ment of the muscular and nervous forces; and the liver and spleen 
had undergone comparatively but slight alterations. The most 
prominent apparent cause of death was the effusion of blood upon 
the base of the brain. The fit which occurred one month ago 
points to a previous derangement of the cerebro- spinal system. 

Was the effusion of blood upon the brain the result of the action 
of the malarial poison alone, or the result of the action of the 
malarial poison upon the delicate structures of the brain already 
altered by previous disease? It is impossible to decide these ques- 
tions positively, but all our observations upon malarial fever would 
lead us to accept the latter supposition. We regard the action of 
the malarial poison as depressing, and not inflammatory. Cerebral 
disturbances in malarial fever appear to be due — first, to the direct 
action of the malarial poison and of the altered blood upon the 
nervous structures; and, secondly, to the stagnation and accumu- 
lation of blood in the capillaries and bloodvessels of the brain, due 
to the diminished action of the heart, arrest and perversion of che- 
mical change in the blood of the capillaries, and loss of power in 
the capillaries themselves. If by previous disease, arising of itself, 
or induced by the intemperate use of ardent spirits, the capillaries 
and bloodvessels of the brain and its membranes lose their tonicity, 
elasticity, and coherency, the simple stagnation and accumulation 
of blood may be attended by a rupture of the altered vessels, 
without any inflammatory action. A strong confirmation of these 
views is the fact that the vigorous administration of the most active 
stimulants, conjoined with sulphate of qu^nia, is the most efficient 



MALAEIAL FEVEE. 



899 



mode of preventing, arresting, and relieving the coma and delirium 
of malarial fever. If the action of the poison was inflammatory, 
this would not be the case. The preceding case shows that we 
may have symptoms of inflammation of the brain in malarial fever, 
without a single pathological alteration after death, cognizable to 
the unaided senses. 

We say cognizcible to the unaided senses^ because the thorough 
knowledge of the nature of malarial fever demands, amongst many 
other things, a thorough knowledge, not only of the appearance 
and chemical constitution of the structures of the cerebro-spinal 
and sympathetic nervous systems, but also a thorough knowledge 
of the physical, chemical, and pathological alterations of these 
structures when acted upon by morbific agents. 

We are actuated by no disparaging spirit, when we assert that 
in the present state of chemical, physiological, and pathological 
science, we are wholly ignorant of the chemical, physiological, and 
pathological relations of the malarial poison to the nervous ele- 
ments. 

In those cases in which the cause of death was not found in the 
pathological alterations of the orgaus and tissues, the question im- 
mediately arises, what destroyed life ? 

In the present state of medical science we can offer suppositions, 
but we can give no decided answer. How difficult luould it he to 
prove or disprove^ that the raalarial poison produced death hy its direct 
action upon the nervous system^ in a manner analogous to the action of 
some of the violent alkaloid and metallic poisons? We know that 
some substances, as chloroform, will produce sudden death in some 
cases, when there is no assignable cause either in the structures 
and forces of the patient, or in the pathological alterations pro- 
duced. 

This peculiar action is said to be due to the idiosyncrasy of the 
patient. May not the fatal action of the malarial poison be due in 
some cases to the idiosyncrasy of the patient ? Has any one ever 
determined upon what an idiosyncrasy depends ? 

3. A comparison of the autopsy of this case with that of previous 
cases shows that in the first stages of malarial fever the liver is first 
engorged with blood, and the slate and bronze color is not at first 
universal, but confined to definite portions. It is an interesting 
fact that in the present case the solitary glands were found enlarged 
even at this early stage of the disease. The mucous membrane of 
the stomach and intestines presented marks of congestion, if not of 



400 



OBSERVATIONS ON 



inflammation. This condition of the mucous membrane is by no 
means characteristic of malarial fever, even when there is great 
tenderness upon pressure of the epigastrium. Tenderness here 
may be due rather to the state of the spleen and liver. The obser- 
vation which we made upon previous cases is also true with regard 
to this, that the slate and bronze color of the liver is not due to 
the formation and distribution through the liver of peculiar dark- 
colored granules. 

4. Although the stimulants and sulphate of quinia did not cure 
the disease, still they aroused the capillary and general circulation, 
and induced the chemical changes. 

The following Tables, drawn up after the Careful Examina- 
tion OF Three Hundred Cases of Malarial Fever, will present a 
Comparative Yiew of some of the most striking Phenomena of the 
Different Forms of Malarial Fever : — 



/ 



MALAEIAL FEVER. 



401 



.2 3 



Soto 



1^ S ^ 



i o so;;:; 



O 03 S-i 



9jn;'B.i8d[ttt9j, 



JO 9JTi;'BJ9dni9Jj 



'8.I8T[dS0t(H'B 
JO 9.Iti;'BJ9C[ai8Jj 



•noT;'BJTc[s9a: 



•asinj 



J «2 



o P 



■9S'B0 JO 'oj)!; 



(M 1— I ,— I 



lO O 
t-" r-I 



q q 



§5; 

_ o 



-goo 

H ^ <i> pS 9 
to c ■ 



1^ a 



^ r-l O D 

3 ft o .2 o 



to 5 



3 . a 



3 to ^ a 
3 as ri a 

3 'O ^ r; 



5 S g 



a oTg^ 



SCO 



q ce 



O 33 P^rH ^ 

a o o -r" „ ® 

^ gn:3 scg a 

O 03 '3 ,2 O • -■ 

;j bx) e3 ^ ^ 

o 2 >>,'o -3 



ft 



a o 



o o 

O CO 

o o 



.q o 
-H CO 
o o 



o o 
CO c-i 
o o 



i '"^ > 



I 2 a 

"•^ bD 

I'll 



cj o a 

oS a o3 



o .~ 



to 



^2 



C3 a'd 



tu 



a 

a-r1 cS o 



--2 ^ 
o ® a 'd 

a " - ■ a g .2 
ftg-ata^^^'a^SlI 

- - °a9->^rf ^ 25el 
ft-d S? «s > ft^--^ 

03'd SlSo.ii.ar^ a 

9 -J? -""-S toa^'^»3'^'S<33'" 
a ^ n- bc ^ a ^ -tj ^ 
3 a a a -ftf^ ^2 ^- I § a a 
co-^-gisias^ig'TSftgus^ft 



-t^ ft-; 



402 



OBSERVATIONS ON 




MALARIAL FEVER. 



403 



•onSno^ jgpnn 



JO oiniBjedraajj 



•oiaqdsonij'B 
JO ajti^ujodniax 



^ 9 

03 Hi 



•trop'B.iidsoa: 



•osinj 



w 2 



•88130 JO -01^ 



I si" 

3 S ^ g 

^ CO ^ 



.2 5^ 



oi c; g ■ 

9 -Ti . 





'^3 


si i 


, of f 
Ly ac 


trongly i 
small d( 
phosph 


I colored 
; strong] 








s •_■ 




•r; ixD 



o o 

ft © 



2 



105.0° 


105.0 


104.8 
105.0 


106 0 


103.2 


104.0 


103.0° 


103.2 


104.0 
101.0 


105.0 


102.0 


103.0 


80.0° 


82.0 


81.0 
74.0 


74.0 


88.0 


o 

CO 


OO 
Tt* 


o 
I 

CO 


40-44 
30-40 


o 

CO 




<M 
CO 


o 


CO 


O CO 
05 O 


o 

03 


o 
o 


CO 
C5 



o o ce 

ai 

« so 

S 2.S 

P h§ 



-s 

i< 9 



2 g >»'S. 
Fi ^ Jh. 



■ft 2 



^fll .91^ r.^^ 



t-^ a 



^ O j3 ft's s 'H 



g p,P 2 °% --^ ftS-^ p. 



a s'3 

2 05 ft 



-« !^ a^ IdI^ 0.2^ 2 &31^ 

































o 




1-1 o 


CO 




Sept, 




Oct. 


Sept, 





404 



OBSEEVATIONS O^T 



•e.iaqdsoraj'B 
JO 8.in;i3.i8duioj, 



•nop'B.iidsaji 



o « 



•esBO JO 'ojii 



i o 



» .2 3 

o .• ;j o 

2 to t- 

!i 3 a5 cS 

a _ s — ! 



a S (E 

r & 3 

^ 3 .2 be 

O V3 o 

=3 '"S s 

•r; P - c« tc 



<5 <1 
■-I o 



7 g -r 

^3 o d 3 

M o 

2 

r1 '73 ^ .rt 

^ d !^ =• 



c3 -c- a 

o ^ OJ 



3 c3 



3 

o 



- - - g.y 



2o.2 § 

J .2 _ „ . 



- °* s - 



i3j a *e 



„ X tE to 
OOP 



5 



Ol r-l 



C5 r3 

■? a 

3 S 



.2 ^ 

to _ 

^ o 

o to 
to 03 

i| 



s 



a s 



2 3 



Isii 



S S S 

< 



r'^ "© 



o o 



> ^ (M 

-IS R 



jH a o . ■§ -2 

^ to .3 IX) :S 



I? 



~5 S -H ,„ 



o to ^ a 



^ 2 . „ cu - 



* 3 ^ 2 
"I tc2 



"3. 

o ', 



■^"1 ^' » s ^ 
o 3 3 =" P 

3 © 2 ^ © 

GJ O 

OD K O 



H p. X 



o 
o 


O 


q 


o i-H o o q q rH 


05 
C5 


03 


C5 


oi oi (»' C5 c: i>.' 

05 02 05 C3 C: C: Ci 


O 
C5 


o 


(M 


q (» CO o c o q 


c5 


CD 
C5 


CO 
CJ 


1^ t-.' !>■" 'X .~' .-i 
C5 c; c: c; — . C". Ci 


o 
o 


O 


o 


o o o o q q q 


c-' 

OD 


«) 


o 

03 


co' -s' c/i CO o — < 
CO CO CO CO X 


00 






-P CO CO C/D -M O 
(M r-l iM IM 








-+i O GO CO CO 

■<j< Tj< i> CO ir: CO o 



o 5 s 



13 fccS: ' 



















CO 






(M <N (M i-H (7q rH r-l 






CO 


05 (?tJ t~ CO O rH 
rH (N rH rH CO 


P< 








CO 






- - - ©C 
O O 



CO CO CO CO 



MALAEIAL FEVEE. 



405 



Characters of Urine. 


Clear amber colored ; sp. gr. 1015; reaction 
strongly acid ; after standing 60 hours, the 
reaction was still decidedly acid. 

The urine contained no urea, and no uric acid. 

After 90 hours, no deposit. 

Urine light colored ; sp. gr. 1020 ; urea and uric 
acid greatly diminished; reaction strongly 
acid. 

Urine orange colored, several shades higher 
than in health, but much less highly colored 
1 than usual in severe cases of malarial fever ; 
sp. gr. 1009 ; contained no uric acid. 
Do. do. do. 
Do. do. do. 

Bright red color ; sp. gr. 1016 ; strongly acid. 
Do. do. do. 
Do. do. do. 
Do. do. do. 
Do. do. do. 
Do. do. do. 


•atiSnox .T9pnti 


1 

106.0° 
97.0 

97.0 

101.0 
96.0 
98.0 

98.5 
97.0 
97.0 

96.0 
91.5 

loi.o 

; 101.5 


jo 9.ITH'BJ9(ica9J, 


100.0° 
79.0 

89.0 

99.0 
89.0 
95.5 

98.0 
90.0 
95.1 

91.0 
88.5 
100.5 
100.0 
103.7 


•9.x9qdsoni}'B 

JO 9.inX'B.I0dUI9Jj 


68.5° 
71.0 

80.0 

81.0 
78.0 
71.0 

87.0 
83.0 
80 0 

73.0 
79.0 
76.0 
73.0 
70.0 


•uop'B.ndsaa 


00 -H (MCD(M 05 <M-H(M -HOCC -Hl>.--D-H-tlCO 
(M CO CO TjH (M CO »0 CO <M <M Tt< rH CO rH rH (M IM (M 


•osinj 


-H >0 »0 0-ti M (M(MO OOC^ OOIOOCOO 
lO COCOCJ 05 rHt^Oq (M-HrH 'frHOC<<i-lC0 


State of Intellect, Skin, Tongue, Pulse, 
Kespiration, &c. 


Intellect wandering ; tongue dry, hard, and rough, and 
coated with dry, brownish-yellow fur ; pulse very 
feeble ; skin cool upon trunk and extremities. 

Intellect wandering ; tongue continues still as dry and 
as rough as a board ; pulse exceedingly feeble ; trunk 
and head cold ; skin covered with cold, clammy sweat; 
saliva strongly acid ; respiration spasmodic ; teeth 
coated with sordes. 

Do. do. do. 

Tongue perfectly dry and rough, feels like sand-paper; 
bright red color. 

Severe vomiting and purgation ; skin of head and ex- 
tremities bathed in cold clammy sweat. 

Severe pain in head ; tongue thickly coated with yellow 
and black fur, tip and edges clean, and of a scarlet 
color ; dry and rough. 

Do. do. do. 
Do. do. do. 
Pulse very feeble ; skin of trunk and head cool; tongue 
dry, rough, and coated. 

Do. do. do. 
Do. do, do. 

Tongue slightly coated with yellow fur, dry and harsh 
to the feeling ; intellect stupid ; pulse very feeble, 
with difficulty counted. 

Do, do. do. 
Do, do. do. 
Restless and stupid ; tongue the same. 

Do, do. 
Restless and stupid ; skin hot, dry, and rough. 
Do. do. do. 


Hour of 

DAY. 


11 A. M. 

11 A. M. 

9i P. M. 
1 P. M. 

1 P. M. 

12 M. 
12 M. 
12 M. 

12 M. 
7 P. M. 
11 A. BI. 

7 P. M. 
2i P. M. 

2 P. M. 
2 P. M. 
2 P. M. 
4 P. M. 


DATE. 


Oct. 17 
" 18 

" 18 
" 10 

Aug. 21 

" 22 
" 23 
" 26 

" 27 
Sept 29 

Sept. 30 
Oct. 1 
" 4 
" 5 
" 10 


•QS-BO JO 




t- OO a> o i-i 

CO CO CO 



406 



OBSERVATIONS ON" 




MALAEIAL FEVER. 



407 



The next subjects which demand investigation are — 

1. The comparison of the circulation, respiration, temperature, 
and chemical changes of the solids and fluids, especially of the 
urine in malarial fever, with similar phenomena in health, and in 
all other diseases. 

2. The action of the medicines employed in the treatment of 
malarial fever. 

3. The comparison of the methods and results of treatment in 
malarial fever with those of other diseases. 

4. Nature of the causes of malarial fever. 

5. Relations of malarial fever to soil, water, atmosphere, and 
climate. 

The discussion of each one of these divisions would occupy as 
much space as the preceding imperfect investigation, and must, 
therefore, be deferred to a future time. 

In concluding these "Observations on some of the Phenomena 
of Malarial Fever" (which have been the result of three years' labor- 
and study, upon more than three hundred Cases of the different 
forms of malarial fever, in Savannah, in Liberty County, in Athens, 
and in Augusta), we would again admit that they are incomplete 
— in fact, nothing more than beginnings in the right direction — 
and again express the hope that the statements, and relations, and 
laws deduced from these observations, will be tested by careful, 
conscientious observers; the errors eliminated, the imperfections 
removed, the results enlarged, and the positive knowledge of the 
phenomena of malarial fever, and of all fevers, established by ob- 
servation, experiment, and reason. 



INDEX. 



A 

Alimentary Canal. 

Pathological changes of in malarial fever, 
231—240. 

Changes in the secretions of the mouth 

during malarial fever, 231. 
Appearance of the tongue in malarial 

fever, 232. 

Pathological alterations of the stomach in 

malarial fever, 232. 

of the intestinal canal, 232. 
Post-mortem examinations illustrating the 

pathological alterations of the stomach 

and intestines in malarial fever, 233 — 

240. 

Arachnoid Membrane. 

Pathological alterations in malarial fever, 
218. 

Illustrative post-mortem examinations, 
224—231. 

Astronomical Phenomena. 
Affect all bodies, 9, 
Gravity, 9. 

Binary stars, and the revolution of our 
sun around a distant centre, illustra- 
tions of the wide reign of the law of 
gravity, 9 — 11. 

Stability of the solar system, 12. 

Order and harmony of the planetary sys- 
tem, 12. 

Relations of plants and animals to the 
force of gravity, and the size of our 
globe, 13- 

Relations of the moon to the earth, with 

its plants and animals, 14. 
Heat of the sun and fixed stars, 16. 
Researches of Pouillet upon heat of fixed 

stars, 16. 

Relations of the fixed stars to the motions 
upon the earth, and to the existence of 
plants and animals, 17 — 20. 

Acalephae, blood of, 80. 

Andral, on the changes of the blood in 
typhoid fever, 198 ; in smallpox, 199 ; in 
measles, 199 ; in erysipelas, 200 ; in phthi- 
sis, 200 ; in acute rheumatism, 202 ; in 
pleuritis, 203 ; in peritonitis, 203 ; in bron- 
chitis, 203. 

— — on the distinctions between the altera- 
tions of the blood in the pyrexia and 
phlegmasiae, 208—210, 

27 



Anemia, changes of blood in, 201. 
Antony, Dr. Milton, on spinal irritation, 
152. 

Arnold, Dr. Richard D., on the color of the 
liver in malarial fever, 244. 



B 

Blood, 75—216. 

Imperfect state of our knowledge, 75. 
Importance and diflBculty of establishing 
a standard formula of the constitution 
of the blood in health, 79. 
The constitution of the blood varies not 
only with the class, but with each spe- 
cies of animals, and corresponds with 
the development and perfection of the 
organs and apparatus, 80. 
Blood of Protozoa, 80. 
Polypi, 80. 
Acalephae, 80. 
Echinodermata, 81. 
Cephalopoda, 82. 
Amphioxus, 82. 
Garfish (lepisosteous osseus), 
83. 

Reptiles, 83. 

Birds and mammalia, 83, 
Chemical constitution of moist blood cor- 
puscles, 84. 
Chemical constitution of liquor sanguinis, 
84. 

Importance of establishing the typical 
formula of the blood in starvation, 85. 

Difficulties of establishing the amount of 
blood in health and disease, 86. 

Estimates of the amount of blood in the 
human system by Blumenbach, Haller, 
Borelli, Young, Dumas, Fletcher, An- 
cell, Valentine, and Lehmann, and by 
the author, 86. 

Changes of the blood in malarial fever, 
88, 216. 

Difficulties of investigations upon the blood 

in disease, 88. 
Color of the blood and serum in malarial 
fever, 91. 

Specific gravity of the blood and serum 
in various diseases, as determined by 
Becquerel, Rodier, Nasse, Zimmerman, 
Guenaud de Mussy, and Joseph Jones, 
93. 

Coagulation of the blood, 93. 



410 



INDEX. 



Blood — continued. 

Table of blood-corpuscles in 1,000 parts 
of healthy and malarial blood, 94. 

Fibrin in healthy and diseased blood, as 
determined by Andral, Gavarret, Bec- 
querel, Rodier, Guenaud de Mussy, 
Popp, Wittstock, Simon, Glover, Heller, 
and Joseph Jones, 94, 95. 

Cases illustrating the physical changes of 
the fibrin, and the formation of heart 
clots in malarial fever, 96 — 112. 

Observations of Hewson, Baillie, Mor- 
gagni, Albinus, Burns, Stewart, "War- 
drop, Cruwell, Graham, Stenzel, Meckel, 
Stoerk, Petit, O'Halloran, Martial, Ba- 
ron, Virchow, Paget, Crampton, Louis, 
Bougen, Desault, Duncan, Reid, Hodg- 
son, Andral, Tiedemann, Otto, Lobstein, 
Cloquet, Carsewell, Langstaff, and Ri- 
chardson, on the formation of fibrinous 
concretions during life, 113 — 115. 

Conditions most favorable to the deposi- 
tion of fibrinous concretions, 115 — 117. 

Observations of Gairdner, Richardson, 
Gaspard, Lee, Hewson, Thackrah, Coo- 
per, and Briicke, upon the coagulation 
of the blood, 116, 117. 

Symptoms and diagnosis of fibrinous con 
cretions in the heart and bloodvessels, 
118—124. 

Observations of Dr. "Wm. Senhouse Kirkes 
upon the efi'ects of detachment of fibrin- 
ous concretions during life, 125. 

Discussion of the causes of the formation 
of fibrinous concretions in the heart 
and bloodvessels in malarial fever, 126 
—129. 

Principles of treatment best adapted to 
prevent the formation of fibrinous con- 
cretions in the heart and bloodvessels, 
129—132. 

Method of analyzing the blood, 133. 

Table illustrating the composition of ven- 
OVTS blood in malarial fever, 135. 

History of the cases which furnished the 
blood for analyses, 136 — 171. 

Comparison of their results with the typi- 
cal formula of the blood in health and 
disease, 171 — 211, 

Colored blood-corpuscles are diminished 
during malarial fevers, and the extent 
and rapidity of the diminution corre- 
spond to the severity and extent of the 
disease, 171. 

Researches of Andral and Gavarret upon 
the blood of intermittent fever, 172. 

Composition of the blood in marsh cach- 
exia, according to Becquerel k Rodier, 
173. 

Composition of the blood in mechanical 

dropsy, 174. 
Composition of the blood in acute dropsy, 

175. 

Composition of the blood in cachectic drop- 
sies, 177. 

The fixed saline constituents of the col- 
ored blood-corpuscles are diminished in 
malarial fever, 177. 

The iron of the disintegrated blood-corpus- 
cles appears in the urine, 178. 



Blood — continued. 

Physiological, pathological, and thera- 
peutical bearing of the changes of the 
blood-corpuscles in malarial fevers, 178 
—193. 

Researches of Schmidt upon the specific 

gravity of the colored blood-corpuscles 

in various diseases, 179. 
Relations of the colored blood-corpuscles 

to the muscular and nervous system, 

179. 

Principles of treatment, based upon the 
changes of the blood in malarial fever, 
180—193. 

Injurious efi'ects of bloodletting in mala- 
rial fever, 180—186. 

Active and excessive purgation should be 
avoided in malarial fever, 187. 

Importance of nutritious diet, and of the 
phosphates and iron, 188. 

Principles which should govern the admin- 
istration of pepsin in malarial fever, 
189. 

The excretion of the products resulting 
from the dead disintegrated blood-cor- 
puscles should be promoted by diuretics 
and depurants, and the liver and spleen 
should be roused to throw ofi' their per- 
verted secretions, 193. 

Place of the destruction of the colored 
corpuscles in malarial fever, 194. 

Animal starch accumulates in the malarial 
liver ; whilst grape sugar is absent, 
195. 

Alterations of the blood, and especially of 
the blood-corpuscles in the spleen during 
malaria.1 fever, 196. 

Comparison of the changes of the blood 
in malarial fever, with the changes of 
the blood in typhoid fever, typhus fever, 
ephemeral fever, smallpox, scarlatina, 
measles, acute scurvy, chronic scurvy, 
erysipelas, cholera, phthisis, scrofula, 
carcinoma, Bright's disease, chlorosis, 
anemia, simple rheumatic fever, febrile 
arthritic rheumatism, rheumatism, puer- 
peral fever, pneumonia, pleuritis, peri- 
tonitis, angina tonsillaris, acute bron- 
chitis, carditis, pericarditis, inflamma- 
tion of brain, glanders, and lead poi- 
soning, 198—203. 

The colored blood-corpuscles are more uni- 
formly and rapidly destroyed in mala- 
rial fever than in any other acute dis- 
ease, 204—207. 

Comparison of the changes of the blood 
and organs in malarial fever, with the 
changes of the blood and organs in ty- 
phoid and typhus fevers, 205 — 207. 

The diminution of fibrin in malarial fever 
corresponds with the severity of the 
disease, 208 

Observations of Andral upon the diminution 
of fibrin in fevers, 208—210. 

Discussion of the question, do these 
changes of the blood precede or suc- 
ceed, or are they simultaneous with, the 
aberration of the physical, chemical, 
vital, and nervous phenomena denomi- 
nated fever, 211—216. 



INDEX. 



411 



Blood — continued. 

Bleeding should be employed with caution 
in malarious districts, 211. 

Sulphate of quinia beneficial in pneumo- 
nia and pleurisy, and irritative fevers 
following amputations, occurring in ma- 
larious countries, 211. 

Observations of the author upon three at- 
tacks of malarial fever, occurring in his 
own person, 212 — 214. 

Observations of Drs. Stevens, Ball, 
Mitchell, Salvagnoli, Archer, Porter, 
and Potter, upon the changes of the 
blood preceding the phenomena of 
fever, 215, 216. 

Brain. 

Pathological alterations of in malarial 
fever, 217—231. 



Cases of malarial fever, illustrating the 
formation of heart-clots, 96 — 112. 

illustrating the changes of the blood in 
malarial fever, 136 — 171. 

illustrating the effects of bloodletting in 
malarial fever, 182. 

illustrating the period at which the 
changes in the blood commence, 212. 

illustrating the pathological alterations 
of the organs, 224—231, 233—240, 
245, 264—270. 

illustrating the phenomena of intermit- 
tent, remittent, and congestive fevers, 
286—293, 301—313, 320—407. 

Cerebro-Spinal Nervous System, 217 — 
231. 

Not the seat in malarial fever of any uni- 
form irritation or inflammation, 219. 

Discussion of the causes of the aberrated 
nervous phenomena of malarial fever, 
220. 

Theory expressing the relations of the 
physical, chemical, and nervous pheno- 
mena of malarial fever, 221. 

Malarial fever paroxysmal not because the 
action of the eerebro-spinal or of the 
sympathetic nervous system is parox- 
ysmal, 223. 

Explanation of the paroxysmal character 
of malarial fever, 221—223. 

Post-mortem examinations of the cerebro- 
spinal nervous system in the various 
forms of malarial fever, 224 — 231. 

Chemical Changes. 

Importance of determining the amounts 
and character in various disease, 271 — 
276. 

Index of temperature, 271 — 276. 
Chemical changes of blood, 88 — 216. 

liver, 195, 240. 

spleen, 196, 259. 

intermittent fever, 
285. 

remittent fever, 312. 
congestive fever, 352. 



Cellulose. 

Investigations of C. Schmidt, Lowig, Kol- 
liker, Odier, Lassaigne, Payen, Chil- 
dren, Danniel, Virchow, Busk, Bennet, 
and Carter, upon, 257. 

Chlorosis, changes of blood in, 201. 

Cholera, changes of blood in, 200. 

Carditis, changes of blood in, 203. 

Campbell, Prof. H. F., on nervous system, 
152. 

Copland, Dr. James, on the relations of the 
eerebro-spinal and sympathetic nervous 
systems to fever, 155, 156. 

Circulation. 

Relations of, to respiration, temperature, 
state of skin, and changes of urine in 
intermittent, remittent, and congestive 
fever, 271—407. 

Importance of its determination, 275. 

Table showing the variations of in differ- 
ent individuals, 277. 

Effects of changes of temperature on, 282. 

Condition of, in the cold stage of intermit- 
tent fever, 285—293. 

In the hot stage, and period of intermis- 
sion, 293—312. 

Cases and tables illustrating the changes of 
the circulation in intermittent, remit- 
tent, and congestive fevers, 301—407. 

Correlation of the Physical and Vital 
Forces, 24—48. 
History of the establishment of the cor- 
relation of the physical forces, 26 — 36. 
Views of the Hindoos, Sabians, Chinese, 
Persians, and Egyptians, of Thales, 
Parmenides, Archelaus, Democritus, 
Pythagoras, Hippocrates, and other an- 
cient philosophers, 26. 
Labors, experiments, reasonings, and 
generalizations in astronomy, of Ar- 
chimedes, Anaximander, Aristotle, An- 
aximenes, Aristarchus, Hipparchus, Pto- 
lemy, Copernicus, Kepler, Stevinus, 
Galileo, Gassendi, Fermat, Riccioli, 
Grimaldi, Bacon, Descartes, Castelli, 
Huyghens, Hooke, Halley, Mersenne, 
Bernoulli, Hermann, Leibnitz, Euler, 
Clairaut, D'Alembert, Lagrange, Gas- 
sendi, Borelli, and Newton, 27, 28 ; 
in acovistics, of Pythagoras, Mersenne, 
Newton, Taylor, Bernoulli, D'Alembert, 
Euler, Lagrange, Laplace, Poisson, 28; 
in thermotics, of Bacon, Locke, Rum- 
ford, Davy, Leslie, Dulong, Clausius, 
Mayer, Magnus, Holtzmann, Regnault, 
Rankine, Thompson, Joule, 29 ; in 
optics, of Seneca, Ptolemy, Archimedes, 
Euclid, Alhazen, Vitello, Snell, Greg- 
ory, Descartes, De Dominis, Newton, 
Huyghens, Grimaldi, Biot, Arago, 
Hooke, Young, Fresnel, Brewster, 30 ; 
of Volta, Nicholson, Davy, Becquerel, 
Faraday, Oersted, Arago, Schweigger, 
31—32,- of Petit, Scheele, Senebier, 
Rumford, Meese, Priestley, Ingenhousz, 
Saussure, Bitter, Wollaston, Young, 
Vogel, Hersehel, Seebeck, Gay-Lussac, 



412 



INDEX. 



Correlation of the Physical and Vital 
PoRC E s — continued. 

Thenard, Berard, Wedgwood, Niepce, 
Daguerre, Draper, 32 ; of Oken, 33 ; of 
Carnot, Vanuxem, Metcalfe, 34; of Dr. 
Samuel Jackson, 35 ; of Grove, Mayer, 
Helmholtz, 35—36. 



D 

Dugas, Prof. L. A., on the pathology and 
treatment of bilious fever, 150 — 152. 
Dura mater, normal in malarial fever, 217. 
Post-mortem appearances, 224 — 231. 



E 

Erysipelas, changes of blood in, 200. 

Earthquakes, illustrating the irresistible en- 
ergy of the force of heat, 21 ; of South 
America, calculations of Sir Charles Lyell, 
21. 

Exterior, 216. 



F 

Fever. 

Intermittent, 93. 95, 135, 139, 285—313. 
Cold stage, 285—293. 
Hot stage, 293. 
Intermission, 293—313. 
Character, urine in, 297 — 313. 
Pulse, respiration, and temperature in, 
285—313. 

Eemittent fever, changes of urine in, 
313. 

Congestive fever, pulse, respiration^ tem- 
perature, and urine, 342--407. 

Illustrative cases, 96, 136—170, 286— 
407. 

Typhus fever, changes of blood in, 198. 
Typhoid fever, changes of blood in, 198. 
Ephemeral fever, changes of blood in, 
199. 

Opinions of Hoffmann, Boerhaave, Cullen, 
Selle, Tode, Thorer, Stoll, J. C. Frank, 
Fodere, Clutterbuck, Alibert, Bayer, 
Nepple, Ford, Dugas, Campbell, An- 
tony, Copland, and Maillot on fever, 
149—166. 

Fibrinous Concretions, 96 — 132. 

Cases illustrating the formation of fibrin- 
ous concretions in malarial fever, 96 — 
112 

Symptoms of, 118. 

Principles of treatment best adapted to 
prevent the formation of, 129. 

Observations of Hewson, Baillie, Mor- 
gagni, Albinus, Burns, Stewart, Ward- 
rop, Cruwell, Grraham, Stenzel, Meckel, 
Stoerk, Baillie, Petit, O'Halloran, Mar- 
tial, Baron, Virchow, Paget, Crampton, 
Louis, Bougen, Desault, Duncan, Reid, 
Hodgson, Andral, Tiedemann, Otto, 
Lobstein, Cloquet, Carsewell, Langstaff", 



Fibrinous Concretions — continued. 

Richardson, Thackrah, Cooper, and 
Briicke upon the formation of fibrinous 
concretions during life, 113 — 125. 

Ford, Prof. Lewis D., on intermitting and 
remitting fever, 149 — 150. 

Frank, J. C, on fever, 149. 



G 

Galileo, 25. 

Gangrsenopsis, or gangrenous erosion of 

cheek, 163—168. 
Gerhard, Dr., observations on typhus fever, 

206. 

Gavarret on typhoid fever, 198. 

Guenaud de Mussy, on typhus fever, 198. 

Gavarret, on smallpox, 199 ; on erysipelas, 
200 ; on phthisis, 200 ; on acute rheumat- 
ism, 202 ; on pleuritis, 203 ; on perito- 
nitis, 203; on bronchitis, 203, 

Glover, on the changes of the blood in scro- 
fula, 200—201. 

Glanders, changes of blood in, 203. 

Grape sugar, absence of, in the malarial fe- 
ver liver, 195 ; 255—258. 



H 

Heart. 

Fibrinous concretions of, 96 — 132. 

Principles of treatment best adapted to 
prevent the formation of fibrinous con- 
cretions in the heart and bloodvessels, 
129. 

Symptoms of fibrinous concretions in the 
heart, 118—124. 

Investigations of Dr. Benjamin Ward 
Richardson upon the formation of fibri- 
nous concretions in the heart, 114, 115 ; 
118—124. 

Observations of Gairdner, Lee, Gaspard, 
Hewson, Thackrah, Cooper, and Briicke, 
upon the formation of fibrinous concre- 
tions in the heart during life, 116, 117. 

Cases illustrating the formation of heart- 
clots in malarial fever, 96 — 112. 

Pathological alterations of, in malarial 
fever, 231. 



I 

Intermittent Fever, 285—312. 
Cold stage, 285—293. 
Changes of blood in, 135—139. 
Changes of urine in, 288—293, 297—312. 
Hot stage and phenomena of intermission, 
393—312. 

Relations between state of skin, pulse, 
respiration, and temperature in, 294 — 
296. 

Theories of Dr. Ford, Dugas, Campbell, 
Lobstein, and Copland, 149 — 156. 

Skin, pulse, respiration, and temperature, 
285—312. 

Illustrative cases, 286—293, 301—314. 
Critical discharges in, 299. 



INDEX. 



418 



Intermittent Fever — contimied. 

Character of deposits in urine, 178, 297, 
■ 301. 

Iodide of quinia useful as a depurant in the 
latter stages of malarial fever, 193. 

Intestines, 

Pathological changes of, in malarial fever, 
232—240. 

Illustrative post-mortem examination, 233 
—240. 

Peyer's glands not enlarged in malarial 

fever, 233. 
Illustrative cases, 233—240. 
Brunner's glands, 233. 
Illustrative eases, 233 — 240, 



J 

Jackson, Prof. Samuel, of the University of 
Pennsylvania, on the correlation of the 
physical and vital forces, 36 ; on the 
relations of the cerebro-spinal and sym- 
pathetic nervous systems, 66 — 70. 

Jackson, Dr. Samuel, of Northumberland, 
Pa., on gangrsenopsis, or gangrenous 
erosion of the cheek, 163 — 168. 

Jenner on typhus fever, 206, 



K 

Kidneys, 

Pathological alterations of, in malarial 

fever, 194, 271. 
Slate and bronze-colored spots upon, 194 

—195, 271, 
Kepler, 10, 25, 

Kblliker on the structure of the liver, 240, 
242. 



L 

Lagrange and Laplace, discoveries of, prov- 
ing the stability of the solar system, 12. 

Liver. 

Cirrhosis of, 247. 

Color of, in malarial fever, 244, 

Color of, in yellow fever, 256. 

Chemical changes of blood in, 194, 195, 

Accumulation of animal starch, and ab- 
sence of grape sugar in malarial fever, 
195. 

Observations of Malpighi, Kiernan, MIH- 
ler, Leidy, Vogel, Henle, Bowman, 
Beale, Budd, and Reid, on the liver, 
241. 

The liver, the fabricator of the blood, re- 
searches of M. CI. Bernard, Weber, Kol- 
liker, Thackrah, Simon, and Lehmann, 
240. 

Difficulties of pathological, anatomical, 
and physiological examinations of the 
liver, 240—243. 

Weight of the liver in malarial fever, 243. 

Color of the liver in malarial fever, 244— 
254. 

27^- 



: VE R — CO ntinued^ 

Observations of Dr. Thomas Stewardson, 
William T, Howard, Swett, Anderson, 
Frick, and Richard Arnold, upon the 
color of the liver in malarial fever, 244 
—254. 

Post-mortem examinations, 245. 

Effects of previous pathological alterations 

upon the color of the liver in malarial 

fever, 246—251. 
Effects of pre-existing cirrhosis upon the 

color of the liver in malarial fever, 246 

—250. 

Changes in the color of the blood in the 

liver of malarial fever, 251-— 252. 
Sources of the changes of color in the liver 

during malarial fever, 252—254. 
Animal starch present in the malarial liver, 

whilst hepatic sugar is absent, 255 — 258. 
Animal starch present in the yellow fever 

liver, 256. 

Occurrence of cellulose and of chitin in the 

animal kingdom, 257. 
Some of the points of difference between 

the malarial fever, and vellow fever 

liver, 258—259. 
Liebig on the fluid contained in the tubules 

of muscles, 180. 
Lecanu on typhoid fever, 198 ; on scarlatina, 

199 ; on carditis, 203. 
Lead-poisoning, changes of blood in, 203. 

Lungs. 

Pathological changes in malarial fever, 
231. 



M 

Mars, character of its surface, 13. 
Moon, its relations to plants and animals, 
14. 

Man, relations to the exterior universe, 7 — > 
49. 

Miiller on structure of liver, 247. 
Maillot on cerebro-spinal fevers, 149. 

Malarial Fevers. 

Changes of blood in, 88 — 216. 
Changes of the liver in, 194, 240—259. 
Researches of Dr. Thomas Stewardson, 
Howard, Swett, Anderson, Frick, and 
Arnold, on the color of the liver in ma- 
larial fever, 244, 245. 
Changes of the pulse, respiration, tempe- 
rature, and urine in, 271 — 407. 
Cases of, 96—112, 135—171, 286—407. 



N 

Nervous System, 56—70, 149—156, 217— 
231. 

Investigations of Willis, 56 ; of Boer- 
haave, 57; of Haller, 57; of Pro- 
chaska, 57 ; of Willis and Vieussens, 
58 ; of Winslow, Girardi, Fontnna, 
Jacobson, Lobstein, Ribes, Killian, 
Laumonier, Cloquet, Scarpa, Hasse, 
58 ; of Prochaska, 58, 59 ; of Bichat, 



4U 



IXDZX. 



Keetous SrsTEir — rontinucd. i 
59: of Le Gallois, 59 : of Lobstein. 61 : , 
of Dr. Samuel Jackson, 66—68; of : 
Claude Bernard. Brown -Sequard, Camp- » 
belL and HaU, 6S. | 
Eelations of tlie cerebro-spinal and sym- ; 
pathetic nervous svstems to disease^ 66 
-71, 149—156, 217—231. 
Eelations of the nervous system to the 
intellectual and moral faculties in dis- 
ease, 72. ; 

Xewton. 25, 23. 



Pakcbeas. 
Xo patholosical alterations of. in malarial 
fever, 270. 

PA>-CREATI^^:. 
Obserrations of M. L. Corvisart on, 192. 

PaTHOLOG-I'~ AL IXVESTIGATI05S. 50 — 75. 

Sc'Urce5 o:" disease, 5'.' — 53. 

Eel: f astronomical changes to dis- 

Efl:.:i;:ii :i climate, soil, and Trater, to 

disease. 51, 52. 
OSces of the nervous system and relations 

Ociri r:: -:::_\rnts, and researches 

o: Erl-c-M-. 't;.'-:-_. Piec olhoBiini. Eio- 



Ian. Plemr:;:^, V'^:^. CI 
Bohn. DtA--:--- Vie-...-. ^ 
More:—-:, E:..::,", ' 1.:, 
Sina^^. H-- II : : i: ■ 

linell:, Pc:::, 

E:-!-::-^:-. Mev.r, Ei^hat. Eiiruv:ren. 
E-::{a = . Bainvi:ie. Provin-l, Vc-lius, 
C.:;;-V.--5 EivEn^ Ei;!::. :Ea:;.:to, 

E^n^ct. P^irtaL ' Procliaska^ V^i^.:'^. 
Le Gallois, Philip, Lobstein. Eeii. 
Krimer. Amemann. Lonsret. Brodie. 

Ch-sat. J.E ^a^se. E.-arE 

Hai:. Ero-a^i a.a;:i, Ca--":E:. 
son, Pi-ooaa-a .a ; ::-r^._ E- 
physiology aa ■ a:_. E aj : E:t jria' : ^ 
spinal and ;-"a_ a ,:.:ar:a: Hcaviu; ivstciii. 
54—71. 

Experiments of Le GaUois upon the rela- 
tions of the cerebro-sp>inal and sympa- 
thetic nervous systems, 59. 

Physiological and pathological researches 
of Lobstein upon the cerebro-spinal and 
sympathetic nervous systems. 61. 

Eesearches of Dr. Samuel Ja::--::r. v.y::: 
the physiological and pathE a::E :a E.- 
tions of the sympathetic aai ccrebao- 
spinal nervous systems, 66. 

Eelations of the intellectual and moral 
faculties to disease. 71, 72. 

Extent and imperfections of pathological 
investigations, 73. 

Pathological Chavges of the OeCtAxs 
AVI' Tissues ly AIalap.ial Fever. -424. 
Ex-arEr. ;iE 
Muscular svstem. 217- 
Head, 217.' 



Pathological Changes of the Orgatt? 
AXD TissrES IN Malarial Fetee — 

contin ued. 

Dura mater. 217. 

Arachnoid membrane, 217. 

Pia mater, 217. 

Cerebrum. 21S. 

CerebreUum, 218. 

Medulla oblongata, 218. 

Ventricles of brain, 217. 

Xervous phenomena of malarial fever com- 
pared with post-mortem examinations. 
219— 23E 

Chest. 231. 

Lan-s, 23E 

EeaE. 231, 

A:E-.-;tarv canal. 231—240. 
M>a:b, 2:E, 
E:aa::., Col, 
<E5^:^rb^au;, 232. 
St'juaach, 232. 
Duodenum, 232. 
Jeiunum. 232. 
Ileum. 232. 

Glands of Peyer, 2-33, 234. 
Solitary glands. 233. 
Liver. 24^:'— 259. 

S'.at- aa i bronze color of liver. 244. 

Cbaaa.s of blood of Kver, 240. 

Malarial i:"ar c :aa:a:-as animal starch, but 

no 'z-r a:ij -a.a: a CiE 
BiE. 2-E, 

^- ar a E: : .-Een. 264. 
Ea ,:'yi—27Q. 

Ccrtrar ^-saiaal nervous system. 217 — 231 ; 
Cerebro-spinal nervous system not the 
seat, in malarial fever, of any uniform 
irritation r aarl: a.naation, 219; discus- 
sion of thr : a T ■ : ; the aberrated phe- 
nomena o: a: : '.a.-a"_ Ever. 22'''. 

Theory exT:r-:a_ :ar ar:.a::as of the 
physical, carni::..:. aa;l nc: us pheno- 
mena of malarial fever, 221. 

Malarial fever paroxysmal, not because 
the a:ii:n :f the cerebro-spinal, or of 
: r a: : ::c nervous system is pa- 

Exalan aEa : the paroxvsmal character 
c;f laE.;:::,.: -ver. 221-^223. 

Post-mortena examinatio-ns of the cerebro- 
spinal nervous svstem in the various 
forms of malarial 'fever, 224—2.31. 

Lungs, 231, 

Heart, 231. 

Alimentary canab 231 — 240: changes in 
the Srji aa ns :; :ae mouth during ma- 
Eiaai Ever, 231. 

Atpearance of the tongue in malarial 
laver, 232 : stomach, 232. 

IntrStinE canal, 232. 

P : s : - in : item examinations illustrating the 
pathob: aical changes of the stomach and 
intestines in naalarial fever. 23^—240 : 
liver. 24'"' — 2 a 9, 

The livci zl^ n." ricator of the blood : re- 
searcaas :: M, CI. Bernard. Weber, 
K'Eiikcr. Ihackrah, Simon^ and Leh- 
mann, 240, 



INDEX. 



415 



Pathological Changes of the Organs 
AND Tissues in Malarial Fever — 
coivtinued. 

Difficulties of pathological, anatomical, 
and physiological examinations of the 
liver, 240—243. 

Difficulty of correct microscopical exami- 
nation of the liver, illustrated by the 
diffei-ences of opinion of Kiernan, Schro- 
der Vander Kolk, Krukenberg, Weber, 
Eetzius, Theile, Backer, Leidy, Beale, 
Kblliker, Handfield Jones, and BL. D. 
Schmidt, 241, 242. 

Weight of the liver in malarial fever, 243 ; 
color of the liver in malarial fever, 
244 — 254; observations of Drs. Thomas 
Stewardson, Wm. T. Howard, Swett, 
Anderson, Frick, and Kichard Arnold, 
upon the color of the liver in malarial 
fever, 244, 245. 

Post-mortem examinations, illustrating 
the changes of color, 245. 

Effects of previous pathological alterations 
upon the color of the liver, in malarial 
fever, 246—251. 

Effects of pre-existing cirrhosis upon the 
color of the liver in malarial fever ; 
observations ofMalpighi, Kiernan, Miil- 
ler, Leidy, Hyrtl, Vogel, Henle, Bow- 
man, and Beale, upon the fibrous tissue 
of the liver ; observations of Dr. Budd 
upon the nature of cirrhosis of the liver, 
246 — 248 ; cases illustrating the effects 
of pre-existing cirrhosis upon the color 
of the liver in malarial fever, 246 — 
250. 

Changes of the color of the blood in the 
liver of malarial fever, 251, 252. 

Sources of the change of color in the liver 
during malarial fever, 252 — 254 ; obser- 
vations of Dr. Clarke on, 252 ; charac- 
ters of the bile in malarial fever, 254, 
"255 ; the liver of those cases which died 
in the active stages of malarial fever, 
contained animal starch, whilst hepatic 
sugar was absent, 255 — 258. 

Animal starch present in the yellow fever 
liver, 256 : researches of C. Schmidt, 
Lowig, and Kblliker, upon the occur- 
rence of cellulose in the animal king- 
dom, 257; researches of Odier, Las- 
saigne, Paj'en, Children, Dannie], and 
Schmidt, upon the occurrence of chitin 
in the animal kingdom, 257. 

Discovery of cellulose in the brain and 
nerves of sense, by Rudolph Virchow, 
257 ; observations of Busk, Virchow, 
Bennet, Carter, Bernard, Sanson, Lon- 
get, Bouley, Poggiale, and Parry, upon 
cellulose and animal starch, 258. 

Some of the points of difference between 
the malarial fever and yellow fever 
liver, 258, 259. 

Spleen, pathological alterations of, in ma- 
larial fever, 259—270. 

Difficulty of determining the offices of the 
spleen, 259 — 263 ; comparative weights 
of the spleens of animals, 259; observa- 
tions of G-ray on Malpighian corpuscles 



Pathological Changes op the Organs 
AND Tissues in Malarial Fever — 
continued. 

of the spleen, 261 ; weight of the spleen 
in malarial fever, 263. 

Cases illustrating the pathological altera- 
tions of the spleen in malarial fever, 
264—270. 

Pancreas, 270. 

Kidneys, 271. 
Pepsin, administration of, in malarial fever, 
189 — 191 ; employment in various dis- 
eases, 189 ; method of its preparation, 
190. 

PiA Mater, pathological alterations of, in 
malarial fever, 216. 

Pulse, 271—407. 

Effects of exercise in cold air upon, 282. 

Intermittent fever, 285 — 314. 

Remittent fever, 314. 

Congestive fever, 314. 

Table showing its variations in different 
individuals, 277; variations during 
twenty-four hours, 278 ; variations dur- 
ing exercise, 282 ; cold stage of inter- 
mittent fever, 285 — 293 ; hot stage and 
period of intermission, 293 — 312 ; in 
remittent and congestive fevers, 314 — 
407. 

Purgation, excessive, should be avoided in 
malarial fever, 187. 

Popp, on the changes of blood in typhoid 
fever, 198 ; in phthisis, 200 ; in simple 
rheumatic fever, 202 ; in inflammation of 
brain, 203 ; in glanders, 203 ; in lead poi- 
soning, 203. 



R. 

Relations of Man to the Exterior Uni- 
verse, 7 — 49. 

Wide reign of the law of gravity, 9. 

Binary system of stars illustrating the 
unity of forces in the universe, 9. 

Uniformity in the forces of the universe 
illustrated by the extent of the orbits, 
and the periods of revolutions of the 
binary systems of stars, 10. 

Mutual relations of the component mem- 
bers of the universe, and the wide reign 
of the law of gravity illustrated by the 
grand march of our sun and planets 
through space, 11. 

Law of gravity absolutely essential to the 
existence of the universe in its present 
condition, 11. 

Phenomenon of gravity, independent of 
all other properties and phenomena of 
matter, 11. 

Cohesion and gravitation necessary pro- 
perties of matter as now constituted, 12. 

The present state of our solar system de- 
pends upon the relations of its compo- 
nent parts, 12. 

Stability of the solar system — discoveries 
of Lagrange and Laplace, 12. 



416 



INDEX. 



Relations of Man to the Exterior Uni- '. 

VERSE — co?itimted. 
Uniformity of the construction, motions, 

and arrangements of the planets, 12. 
Relations of organized beings to the size 

and structure of our globe, and to its 

relations with the sun and moon, and 

planets and fixed stars, 13. 
Dependence of organized beings upon the 

relations of the moon to our earth, 

14. 

Existence of organized beings dependent 
upon the distance of the earth from the 
sun, 15. 

States of matter, solid, fluid, and gaseous, 
dependent upon the forces acting upon 
the atoms ; the distance of the atoms 
from each other, and the stability of the 
matter which they form, depend upon 
the action of two antagonistic forces, 
cohesion and heat, 15. 

Sun and fixed stars, the sources of the 
heat which maintains the matter of our 
globe in its present conditions, 15. 

Heat supplied to our earth by the fixed 
stars, 16. 

The fixed stars supply as much heat, ac- 
cording to Pouillet, as would melt a 
layer of ice, 85 feet thick, covering the 
whole globe, 16. 

The solar heat constitutes only two-thirds 
of the entire quantity of heat supplied 
to the earth, 16. 

Geological changes explained by the heat 
of the fixed stars, and the motion of 
our system through the ocean of space, 
17. 

Motions in the atmosphere and crust of 

our globe due to the forces of the sun 

and fixed stars, 17. 
Constitution, properties, and motions of 

the atmosphere, trade-winds, land and 

sea-breezes, 18. 
Dependence of organized beings upon these 

motions of the atmosphere, excited by 

the forces of the sun and fixed stars, 

19. 

Relations of the atmosphere to moisture, 
19. 

Latent heat, an instance of the conversion 
of heat into mechanical force ; illus- 
trates the law that action and reaction 
are equal, and that force is indestruc- 
tible, 19. 

Force of the heat of the sun expended in 
evaporation expressed in horse power, 
19. 

Work accomplished by the heat of the 
sun in evaporation upon the whole sur- 
face of the earth, 19. 

This work of the sun compared with that 
accomplished by the steam-engines of 
the world, 19. 

Effects of the heat of the sun, illustrated 
by the power of Niagara Falls, 19. 

Effects of the everlasting circulation of air 
and water carried on by the forces of 
the sun upon the continents, solid rocks, 
and mountains of the earth, 20. 



Relations of Man to the Exterior Uni- 
verse — CO 7iti?iued . 
Relations of organized beings to this ever- 
lasting round of the waters and atmo- 
sphere, 20. 
Our globe originally in a state of fusion, 
20. 

Disintegration of the solid barren rocks, 
and the preparation of a soil suitable 
for the habitation of plants and animals, 
effected by the circulation of water and 
air, under the action of heat and gravi- 
tation, 20. 

Irresistible energy of the force of heat dis- 
played in the discharges of gas, steam, 
mud, and melted lava from the craters 
of volcanoes, 21. 
Illustrated by the earthquake in South 
America, in November, 1822 ; calcula- 
tions of Sir Charles Lyell : the effects of 
the earthquake compared with the dis- 
charge of mud in one year by the river 
Ganges ; great eruption of Skaptara 
Jokul, in Iceland; the fiery strife in the 
bowels of the earth, under the guidance 
of intelligence, 21. 
Every earthquake and every flood has 
contributed to the formation of a suit- 
able soil for the maintenance of plants 
and animals, and the development of 
the human race, 22. 
Every form of matter is definitely related 
to every other form of matter, and the 
arrangements and distribution of the 
terrestrial masses, although the results 
of the action of the forces of heat and 
gravitation, reveal a great design, 22. 
The combination of these various relations 
and actions, and reactions of terrestrial 
masses, form the essential conditions 
of the existence of plants and animals, 
22. 

The history of nations has, in a great 
measure, been determined by the agen- 
cies of heat and gravitation upon mat- 
ter the effects of the arrangement and 
structure of terrestrial masses upon the 
development and progress of intelligence 
and knowledge, and science, illustrated 
by a comparison of the four continents 
— Africa, Europe, Asia, and America, 
23. 

Bodies composing our globe divided into 

two classes, inorganic and organic, 36. 
Inorganic bodies necessary for the exist- 
ence of living beings ; phenomena of 
plants and animals more complicated 
and less general than those of inorganic 
bodies, 36. 
Elementary bodies — development of heat, 
light, and electricity during the union 
of these elements, 23. 
The manifestation of physical and chemi- 
cal phenomena are similar in all bodies, 
differing in degree and not in kind, 23. 
Just as much force is always given out 
■ i during the combination of the element- 
' ary bodies as was required to separate 
j those bodies from their compounds 



INDEX. 



417 



Relations op Man to the Exterior Uni- 
verse — continued. 

(overcome the force which united the 
dissimilar elements), whether that force 
be exerted in the laboratory of the 
chemist, by heat, or by electricity, or 
by bringing other chemical affinities 
into play, or in the great laboratory of 
nature by the action of the heat, elec- 
tricity, and chemical forces of the sun, 
24. 

In the exertion of even force in the uni- 
verse, whether between the great worlds 
or systems of worlds, or between the 
atoms of matter, whatever be the origin, 
character, or intensity of that force, the 
great law of Newton holds good — action 
and reaction are equal, 25. 

Correlation of the physical forces, 24, 25. 

Conversion of heat into ordinary motion, 
25. 

Conversion of ordinary motion into heat. 
24. 

Correlation of the physical forces illus- 
trated by experiments with the galvanic 
battery ; chemical action developing 
electricity ; and this in turn developing 
chemical action ; and the union of the 
products of that chemical action giving 
out the original amount of force de- 
veloped during the chemical changes in 
the cells of the battery, 24. 

Conversion of heat into electricity, and of 
electricity into heat, 24. 

Force indestructible, 25. 

We may change the direction of forces, 
but we can no more destroy force than 
we can annihilate matter, 25. 

The three great fundamental laws of mo- 
tion discovered by Kepler, Galileo, and 
Newton: 1. A body at rest cannot of 
itself begin to move ; and a body in 
motion cannot change its velocity nor 
its direction of motion without the ac- 
tion of some extraneous cause. Any 
body impelled by a single force will 
move in a right line, and with uniform 
velocity. 2. Independence or coexist- 
ence of motions, leading to the compo- 
sition of forces. 3. Constant equality 
of action and reaction. One body mov- 
ing another loses precisely as much mo- 
tion, in proportion to its mass, as the 
body moved gains ; although applied 
by them alone to mechanical motions, 
are applicable to all the various motions, 
astronomical or terrestrial, of inani- 
mate and animate bodies, 25. 

The establishment of these laws is neces • 
sarily followed by the admission that 
force is indestructible. The store of 
force with which the Creator has en- 
dowed matter can neither be added to 
nor detracted from by man, 25. 

Without this mutual relation of all the 
different forces, without this conserva- 
tion of force, the universe could not be 
maintained in its present conditions, 
25. 



Relations of Man to the Exterior Uni- 
verse — cont imied. 

History of the correlation of the physical 
forces, 26—36. 

Plants and animals composed of inorganic 
elements, 37. 

The relative proportions of these elements 
entering into the constitution of plants 
and animals correspond in a great 
measure to the relative quantities of 
these elements in the exterior world, 37. 

The number of elements composing the 
great mass of the crust of our globe is 
very small, 37. 

Distribution and amount of water on our 
globe, 37. 

Circulation of water through the struc- 
tures of plants and animals analogous 
to the grand circulation of water in the 
surrounding atmosphere, and over the 
surface of the earth, 38. 

Water in the organized world, as in the 
inorganic, is the great medium of 
change, and the great agent in the re- 
moval of disintegrated, chemically al- 
tered, oflTending substances, 38, 39. 

Amount of water annually required for 
the circulation through the textures, the 
distribution of the nutritive materials, 
and the removal of the waste products 
of the billion inhabitants of the earth, 
38. 

Amount of oxygen consumed by animals 

and vegetables, 38. 
Offices of oxygen in the animal economy, 

38. 

Relations of animated beings to inorganic 

matter, 39. 
Vital force, 40 — 45. 

Discussion of the nature and relations of 
the vital principle to the physical, chem- 
ical, and nervous forces, 40 — 49. 

Without the physical forces, the vital 
principle can accomplish nothing, 40. 

The vital principle acts in a manner ana- 
logous to the intelligence, 40. 

The laws of physics apply to all the physical 
and chemical changes of vegetables and 
animals, 345. 

General view of the phenomena of man. 
47—49. 

Respiration. 

Variations of respiration in different indi- 
viduals, 277. 

Method of determining, 281. 

Effects of exercise in cold air upon, 282. 

Variations of, in intermittent, remittent, 
and congestive fevers, 285 — 407. 



S. 

Skin. 

Relations of in malarial fever to the pulse, 
respiration, and temperature of extremi- 
ties and trunk, 294—297. 

Spleen, 196, 259—270. 

Pathological alterations of, in malarial 
fever, 259—270. 



418 



INDEX. 



Spleen — continued. 

Difficulty of determining the offices of the 
spleen, 259—263. 

Comparative weights of the spleens of ani- 
mals, 259. 

Weight of the spleen in malarial fever, 263 
Cases illustrating the pathological altera- 
tions of the spleen in malarial fever, 
264—270. 

Scarlatina, changes of blood in, 199. 

Smallpox, changes of blood in, 199. 

Scurvy, changes of blood in, 199, 200. 

Scrofula, changes of blood in, 200, 201. 

Stevens on the changes of the blood in the 
marsh fevers of America and West In- 
dies, 215. 

Starch, animal, occurrence in the malarial 
fever, 195, 255—258. 

Researches of M. CI. Bernard upon, 195. 

Schmidt on the occurrence of cellulose in 
the mollusca, 257. 

Stewardson, observations on the pathologi- 
cal changes of the liver in malarial fever, 
244. 

Stomach. 

Pathological alterations in malarial fever, 
232, 233—240. 
Swett on the color of the liver in malarial 
fever, 244. 



T 

Tables. 

Composition of 1000 parts of moist blood- 
corpuscles, 84. 

Composition of 1000 parts of liquor san- 
guinis, 84. 

Composition of 1000 parts of blood, 84. 

Composition of 1000 parts of serum, 84. 

Specific gravities of the blood and serum 
in various diseases, 93. 

Blood-corpuscles in 1000 parts of healthy 
and malarial blood, 94. 

Fibrin in 1000 parts of healthy and dis- 
eased blood, 94, 95. 

Chemical changes and composition of 
venous blood in malarial fever, 135. 

Pulse, respiration, and temperature, in 
case of intermittent fever, 138. 

Tongue, skin, pulse, respiration, tempera- 
ture, and urine, in remittent fever, 141, 
143 ; in remittent and typhoid fevers, 
145 ; in congestive fever, 160, 169, 

Composition of blood in intermittent fever 
according to Andral, 172. 

Composition of blood in marsh cachexia, 
according to Becquerel and Bodier, 172 ; 
in mechanical dropsy, 174; in acute 
dropsy, 175 j in cachectic dropsies, 
177. 

Constitution of the blood in various dis- 
eases, 198—203. 

Weight of the spleen in malarial fever, 
263. 

Weight of the spleen in various animals, 
259. 

Weight of the liver in malarial fever, 243. 



Table s — continued. 

Table shoAving the loss of weight and 
amounts of urine excreted by cold and 
warm blooded animals deprived of food 
and drink, 273. 

Table showing the variations of the pulse, 
respiration, and temperature of different 
individuals and races, 277 — 280. 

Tables of the variations of temperature 
during 24 hours, and during different 
seasons of the years, 278, 279. 

Variable temperature of man, 277 — 281. 

Variations of the temperature of different 
races, 280. 

Temperature of the insane, 281. 

Phenomena of intermittent fever, 301 — 
310. 

Phenomena of remittent fever ; cold stage, 
hot stage, and intermission of intermit- 
tent fever; cold stage, hot stage, remis- 
sion and intermission of remittent fe- 
ver ; pulse, respiration, temperature, 
tongue, skin, intellect, and urine, in 
congestive fever, 316 — 407. 

Temperature, 271 — 407. 

Variations of temperature in different in- 
dividuals, 277—281. 

Variations of temperature during 24 hours, 
and during different seasons of the year, 
278. 

Observations of Dr. John Davy on tem- 
perature, 278—281. 

Variations of the temperature of different 
races, 280. 

Temperature of the insane, 281. 

Method of determining the temperature, 
281. 

Effects of the temperature of the sur- 
rounding medium, and of exposure to 
cold air upon, 272. 

Changes of, in malarial fever, 271 — 407. 

Importance of determining the relations 
of, to the pulse and respiration, 275. 

Tables showing its variations in different 
individuals, 277—281. 

Importance of attending to the surround- 
ing temperature in the determination of 
animal temperature, 282, 283. 

Temperature in intermittent fever, cold 
stage, 285 — 293 ; hot stage and period 
of intermission, 293 ; in remittent and 
congestive fevers, 217 — 407. 

Tongue. 

Appearance in malarial fever, 232, 297. 



U 

Urine. 

Importance of examining the chemical 

constitution, 271. 
Method of analyzing, 283. 
Works treating of the urine, 283, 284. 
Method of separating urea, 283. 
Method of separating uric acid, 284. 
Changes of, in intermittent, remittent, and 

congestive fevers, 271 — 407. 



INDEX. 



419 



Urine — continued. 

Table showing the amount excreted by 

cold and warm-blooded animals, 273. 
Relations to temperature and muscular and 

nervous force, 274 — 276. 
Difficulties of determining the amounts 

excreted during disease, 283. 
Method of analyzing the urine — references 

to the best treatises upon the urine, 

283—285. 

Characters of, during cold stage of inter- 
mittent fever, 287—293. 

Hot stage and stages of intermission, 297 
—312. 

Urea, changes in intermittent fever, 297 
—312. 

Uric acid, changes in intermittent fever, 
297—312. 

Characters of urine in remittent and con- 
gestive fevers, 317 — 407. 



W 

Water, relations to plants and animals, 
19, 29 ; power of, 19 ; circulation of car- 
ried on by the heat of the sun, 19. 

Wittstock, on the changes of the blood in cho- 
lera, 200. 

Weights of the liver in malarial fever, 343. 
Weights of the spleen in malarial fever, 263. 
Weights of the spleen in various animals, 
259. 

Wurtzel on the nervous system, 58. 



Y 

Yellow fever, color of liver in, 256. 
Color of decoction of liver, 258. 
Pathological differences from malarial 
fever, 258. 



